UNIVERSITY STUDENT HEALTH SERVICES
Stephen F. Austin State University, Nacogdoches, Texas 75962
Medical History:
Name: ___________(STICKER)___________________________________ Date: __________
Best contact telephone # for you: _________________________________________________________________
Home Address: ______________________________ City: ____________________ State: __________ Zip: __________
Emergency Contact: ____________________________________________________________________________________
(Print Name)
Phone No. (
)
Cell No.: (
)
This information you provide is strictly for the use of SFASU Health Services and will not be released to anyone without your knowledge and
consent. This information is used solely as an aid in providing you with necessary healthcare.
List current medications you take:
List any medications you cannot take because of allergy or
other reasons:
List previous hospitalizations and surgeries with dates:
Surgeries:
Other Hospitalization(s):
Personal Health History: Mark an X in the box next to any of the following illnesses you have ever had:
⃝
⃝
⃝
⃝
⃝
⃝
⃝
Measles
German Measles
Mumps
Chickenpox
Infectious mononucleosis (mono)
Sexually transmitted disease
Rheumatic fever
⃝ Tuberculosis or a positive
tuberculin skin reaction
⃝ Ear, nose and throat infection
(more than 2 per year)
⃝ Thyroid disorder
⃝ Low blood sugar
⃝ Eczema or chronic skin rashes
⃝ Hives
⃝ Chronic indigestion or stomach
problem
⃝ Weight loss or difficulty
maintaining weight
⃝ Muscle weakness or paralysis
⃝ Impaired vision
⃝ ADD/ADHD
⃝ Hernia
⃝ Hemorrhoids
⃝ Neuralgia
⃝ Depression
Women Only:
⃝ Irregular menstruation
⃝ Severe menstrual cramping
⃝ Excessive menstrual bleeding
Have you/family member ever been treated for:
Condition
Allergies/Hayfever
Arthritis
Asthma
Blood Clots
Blood Pressure Problems
Cancer (type)
Diabetes
Epilepsy
You
Family
Member
Condition
Heart Disease
Kidney Disease
Liver Disease
Migraines
Peptic Ulcers
Psychiatric
Thyroid Problems
Tuberculosis
You
Family
Member