Medical History
Return by July 1, 2013
H E A LT H C E N T E R
PERSONAL & FAMILY HEALTH HISTORY
* Mark all that apply
Last name
First name
Date of Birth
Current
Past
Treatment
Student #
Student’s cell phone #
Student’s Home Street Address
Home City
Home State
□ I am a Freshman
□ Female
1.
2.
3.
4.
5.
6.
□ I am a Transfer Student
□ Male
Primary Care Provider
•
Name:
•
Phone #:
8.
Medical Specialist – (if applicable)
•
Name:
•
Phone #:
• Specialty:
•
•
Zip
Height
Weight
Medication and/or Food Allergies
Name
Reaction
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Medications taken regularly
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Hospitalizations/Surgeries Please list
________________________________________________________________
________________________________________________________________
________________________________________________________________
I am taking medication or have a medical condition which lowers my immune
system.
No
Yes (name)
I have had Chickenpox disease
No
Yes (age or year)
I have had a positive test for Mononucleosis
No
Yes (month/year)
7.
•
MYSELF
MI
In My
Family
( Who)?
AutoImmune Disorders
Multiple Sclerosis
Systemic Lupus
Other:
Blood Disorders
Anemia
Clotting Disorder
Sickle Cell trait/disease
Other:
Cancer
Specify:
Cardio/Pulmonary Disorders
Asthma
Blood Clots
Heart Disease
High Blood Pressure
High Cholesterol
Other:
Digestive Disorders
Crohn's Disease
GERD
Peptic Ulcer
Irritable Bowel Syndrome
Other:
Eating Disorders
Anorexia Nervosa
Binge Eating
Bulimia
Other:
Endocrine Disorders
Diabetes
Thyroid condition
Other
Mental/Emotional Disorders
Anxiety
Bipolar Disorder
Depression
Schizophrenia
Suicide Attempt
Other:
Neurological Disorders
ADD/ADHD
Cerebral Palsy
Concussion(s)
Migraine Headaches
Seizures
Other:
Reproductive Health
Amenorrhea
Dysmenorrhea
Ovarian cysts
Other:
STATEMENT OF AUTHORIZATION
The information contained on this form is complete and I have not withheld any medical or mental health information. If any aspect of my health
profile changes after submitting this form, I will notify the Hope Health Center of this/these changes in writing.
I authorize the Student Health Center of Hope College to administer medical and surgical services, including immunizations and to perform routine
and emergency diagnostic and therapeutic procedures as deemed necessary by duly licensed medical personnel. I understand that the Medical
Director, or designee, serves as primary physician for medical care provided by the Hope Health Center.
I understand that I will be required to undergo medical treatment for any current or future diagnosis of Latent Tuberculosis Infection (LTBI). Failure
to do so will result in withdrawal from current coursework and living arrangements at Hope College.
Signature of Student
Date