Rockford University Health History Form
Student Athlete: Yes___ No___
Name_________________________________________________________
Last
First
Date of Birth ________________
Middle Int.
Home Address___________________________________________________________________________________________
Street
City
State
Zip Code
Campus Box __________________Cell Phone __________________________ Email__________________________________
Emergency Contact_____________________________ Relation_________________ Cell Phone_________________________
*******Health Insurance plan: Attach copy of the front and back of student’s insurance card*******
Insurance Company Name_____________________ Policy#___________________________
Group#__________________ Policy Holder____________________________ Relationship__________________
Contact # for out of plan service_____________________________________ Is this an HMO? Yes____ No_____
PAST/CURRENT PERSONAL MEDICAL HISTORY: Have you ever had any of the following? Check all that apply.
Endocrine
 Adrenal Disorders
 Diabetes
 Polycystic Ovary
Syndrome (PCOS)
 Thyroid Disorder
 None
Heart/Lungs
 Asthma
 Heart Disease
(valve, vessel,
rheumatic)
 Heart Murmur
 High Blood Pressure
 High Cholesterol
 Pneumonia
 None
Ears/Eyes/Nose/
Throat
 Vision Correction
Glasses
Contacts
 Eye Disorders
 Chronic Sinus
Infections
 Nasal Allergies/Hay
Fever
 Hearing Loss
 None
Stomach/Bowel
 Celiac Disease
 Irritable Bowel Syndrome
 Stomach/Duodenal
Ulcers
 Ulcerative Colitis/Crohn’s
 Other Liver, Stomach, or
Bowel disease
 Gall Bladder
 None
Neurological
 Concussions
How many? _____________
When? _________________
 Convulsions/Seizures
 Migraines/Severe Headache
 Multiple Sclerosis
 Muscular Dystrophy
 Stroke/TIA
 None
Infectious Diseases
 Chickenpox/Varicella
 Hepatitis Type:_____
 HIV Infection
 Infectious Mono
 Measles/Mumps/
Rubella
 MRSA
 Tuberculosis
 None
Hematology/Oncology
 Anemia
 Bleeding Disorders
 Blood Clots/Clotting
Disorders
 Cancer
 Radiation Therapy
 Sickle Cell Anemia
 None
Mental Health
 ADD
 Alcohol Abuse
 Anorexia -Eating Disorder
 Anxiety Disorder
 Bulimia-Eating Disorder
 Depression
 Drug Dependency
 Other Mental Health
Problems
 None
Orthopedics
 Arthritis
 Back Problems
 Fractures/Broken
Bones/Stress Fractures
 Hernia
 Tendonitis/Bursitis
 None
Surgical History
 Appendectomy
 Adenoidectomy
 Bone Marrow
 Ear Tubes
 Gallbladder
Removal
 Organ
Transplant
 Ovarian Cyst
Removal
 Splenectomy
 Tonsillectomy
 Weight Loss
Surgery
 Knee ACL Repair
L ___R ___
 Shoulder
L ___R ___
 Other Prior
Surgeries
 None
List any
Allergies
__________
__________
__________
__________
__________
None
OB/GYN
 Endometriosis
 Pregnancies
#:______
 Irregular Periods
 Painful Periods
or Excessive
Bleeding
 None
STDs
 Chlamydia
 Genital Herpes
 Genital Warts
 Gonorrhea
 HPV
 Other STD
 None
Skin
 Acne
 Eczema
 Psoriasis
 Hives
 Herpes
 Rashes
 Pilonidal Cyst
 None
Kidney
 Chronic Kidney or Bladder Disease
 Kidney Stones
 UTI
None
Please explain any checked boxes:

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Family History:
Yes No Additional Comments
Does anyone in your family have or have they ever had high blood pressure?
Does anyone in your family have or have they ever had high cholesterol?
Does anyone in your family have or have they ever had heart disease (including
heart attack or congenital disorders)?
Does anyone in your family have or have they ever had diabetes?
Does anyone in your family have or have they ever had Asthma?
Does anyone in your family have or have they ever had Sickle Cell Anemia?
_________________________________________________________________________________
Lifestyle Review:
Yes
No
Additional Comments
Do you drink caffeinated beverages such as coffee, black teas or cola?
Do you use tobacco products (cigarettes, cigars, snuff/chewing tobacco)?
Do you drink alcohol?
Do you usually drink more than 4 or 5 drinks in one social session?
Have you felt you ought to cut down on your drinking?
Do you use marijuana, or any other street or recreational drugs?
If so, what kind and how often?
Do you do any physical activity?
If so, what type and how often?
Have you lived or traveled outside the U.S. in the last two years?
If so, where?
Do you have concerns regarding sexuality or gender orientation?
Are sexually transmitted infections or pregnancy prevention a concern?
Do you have concerns about your weight?
Are you on a special diet?
_______________________________________________________________________________
Stress/Emotional Health:
Yes
No
Additional Comments
Have you experienced major changes or problems in the past year
(e.g. personal or family relationships, finances, job)? If so, please explain:
Have you felt anxious much of the time in the past year? If so, have you
received counseling and /or medication?
Have you felt sad or depressed much of the time in the past
year? If so, have you received counseling and/or medication?
Has anyone ever sexually, physically or emotionally abused you
(including repeated hitting, name-calling, or loud criticism;
childhood sexual touching by someone older than you; or rape)?
Would you like to discuss stress/emotional concerns?
Would you like to discuss any other concerns including social, cultural,
religious, or gender-related issues?
_________________________________________________________________________________
Exercise:
Yes No Additional Comments
Has a doctor ever denied or restricted your participation in sports for any reason?
Have your ever passed out or nearly passed out during or after exercise?
Have you ever had discomfort, pain, tightness or pressure in your chest during exercise?
Does your heart ever race or skip beats (irregular beats) during exercise?
Do you have frequent muscle cramps when exercising?
*******Please List any Medications and/or Supplements that you are currently taking*******
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I HEREBY STATE THAT MY ANSWERS ON THIS HEALTH HISTORY
_______FORM ARE COMPLETE AND CORRECT:
Signature__________________________________________________________Date________________________________