NAME
Coulter Student Health Center
Golden, CO 80401-1887
HEALTH HISTORY
LAST (FAMILY)
DATE OF BIRTH
FIRST
SEX:
NUMBER AND STREET NAME
CITY
HOME PHONE NUMBER
EMERGENCY CONTACT NAME
I PLAN TO ENROLL IN (check one)
STATE
□F □M
ZIP CODE
MOBILE PHONE NUMBER
□
FALL
□
RELATIONSHIP
SPRING
□
PHONE NUMBER
SUMMER SEMESTER
PERSONAL HISTORY check box i f your answer is yes.
□ Hearing loss
□ Heart problems
□ Hemorrhoids
□ Hepatitis/liver problem
□ High blood pressure
□ Insomnia
□ Kidney stone
□ Kidney/bladder infection
□ Knee problems
□ Mononucleosis
□ Neck problem
□ Recurrent abdominal pain
□ Rheumatic fever
□ Scoliosis
□ Seizures/convulsions
□ Shortness of breath
□ Shoulder dislocation
□ Skin problem
□ Thyroid disease
□ Tobacco use
□ Tumor/cyst (benign)
□ Ulcer (duodenal or stomach)
□ Unexplained weight loss/gain
□ Use of laxatives, diuretics or vomiting
to control weight
MEDICATION ALLERGIES
OTHER ALLERGIES
Have you ever had any illnesses/injuries other than those noted (if yes, specify)?
Have you had any operations (if yes, what type and how old were you)?
Do you have any type of disability/condition which limits functioning (if yes, specify)?
Please list any drugs, medicines, vitamins, minerals, supplements you use:
FAMILY HISTORY Have any of your relatives ever had any of the following (please state relationship ie: grandfather, aunt, cousin)?
Addiction (include type)
Heart disease
Asthma
High blood pressure
Blood disease (include type)
Mental illness
Cancer (include type)
Stroke
Diabetes
Tuberculosis
This is to certify that the above information is correct to the best of my knowledge.
Student Signature
Date
TO PARENT OR GUARDIAN OF MINOR STUDENTS:
I consent to have my son/daughter receive routine treatment at the Coulter Student Health Center or local hospital should he/she become ill or injured
while at school.
Parent/Guardian Signature
Date
MIDDLE INITIAL
□ Depression
□ Diabetes
□ Diarrhea
□ Dizziness/vertigo
□ Ear/nose/throat problem
□ Eye problem
□ Fainting/syncope
□ Frequent headaches/migraines
□ Frequent vomiting
□ Frequent worry/anxiety
□ Gall bladder problem/gallstones
□ Gout
□ Head injury/concussion
YEAR
FIRST
□ Acne problem
□ ADD/ADHD
□ Anemia
□ Anorexia Nervosa
□ Arthritis/Rheumatism/Bursitis
□ Asthma
□ Back problem
□ Binge eating episodes
□ Bone/joint injury/deformity
□ Cancer, type:
□ Chemical dependency
□ Chronic sinusitis
□ Constipation
CWID#
PLACE OF BIRTH
MM/DD/YYYY
HOME ADDRESS
MIDDLE INITIAL
LAST (FAMILY)
NAME