Indiana State University College of Health and Human Services
Student Health History
PERSONAL INFORMATION
NAME (LAST)
(FIRST)
(MIDDLE)
STUDENT ID (991) NUMBER
M AIDEN/FORMER NAME
DATE OF BIRTH
(MO/DAY/YR)
/
/
PHONE
CELLULAR PHONE
HOME ADDRESS
CITY STATE
,
UNIVERSITY ADDRESS
CITY STATE
,
WHEN DO YOU EXPECT TO ENTER COLLEGE? Semester
Year
IN WHAT PROGRAM / TRACK WILL YOU BE STUDYING:
NEAREST RELATIVE’S ADDRESS
CITY STATE
,
EMERGENCY PHONE
PLACE OF BIRTH
CITY STATE
,
FAMILY PHYSICIAN NAME:
PHONE
ARE YOU UNDER PHYSICIAN’S CARE AT THIS TIME:
YES
NO
MEDICAL INSURANCE COMPANY:
Are you a Veteran:
Yes
No Year of discharge:
Are your parents, brothers, and sisters all living ?
Yes
If not, give age(s) and cause of death:
Allergies to Medicines
Reaction (Rash, etc)
Are you receiving allergy injections:
Yes
GENDER
E-MAIL ADDRESS
@
.
ZIP CODE
ZIP CODE
Status:
ZIP CODE
-
IF SO, FOR WHAT:
No
Other Allergies
No W i l l t h e s e c o n t i n u e i n c o l l e g e :
Reaction
Yes
No
(B e s u re t o l i s t a l l e rg e n s a b o v e )
Did you take Physical Education (PE) in high school:
Yes
No
If there is any reason why you cannot take PE, please report to the Student Health Center in
person before classes begin and bring with you a signed statement from your physician with your
diagnosis.
PAST MEDICAL PROCEDURES
(Include colposcopy, tubal ligation, biopsies, colonoscopy, ear tubes, and transplants. Removal of:
tonsils, adenoids, gall bladder, appendix, wisdom teeth, etc.)
Procedure
Date
Physician/Surgeon
Agency
Complications
Admit Date
HOSPITALIZATIONS /EMERGENCY CARE OR VISITS
Discharge Date
Hospital
Diagnosis
Medications Currently Taking
Description
Reason for Taking Medication
SOCIAL HISTORY / HEALTH HABITS
Occupation:
Marital Status:
Do you participate in any sports activities: Yes
No I f YE S , l i s t s p o rt s :
Do you smoke cigarettes:
Yes
No
No, but I did in the past
Number of years you have / did smoke:
Number of packs / day: More than 2 packs per day
Do you smoke a pipe or cigars:
Yes
No Do you used snuff or chewing tobacco:
Yes
No
Do you drink alcohol (incl beer, wine, hard liquor)
Yes
No If yes: More than 14 drinks per week
HAVE YOU HAD OR DO YOU NOW HAVE ANY OF THE FOLLOWING:
Allergy / Hay
Fever
Asthma
Anemia
Appendicitis
Bone / Joint
Disease
Chronic
Cough
Constipation
Diabetes
Eye diseases
Fainting
Spells
Foot
problems
Gall Bladder
problems
Headaches /
Migraines
Heart
problems
Hemorrhoids
High Blood
Pressure
Dislocations
Indigestion/
GERD
Drug
reactions
Kidney
disease
Liver disease /
jaundice
Malaria
Scarlet fever
Meningitis
Sickle Cell
disease
Sinus problems
Measles
Skin problems
Mumps
Tuberculosis
Mononucleosis
Tumor, Growth,
Cyst, Cancers
Ulcers
Upper
Respiratory
Whooping
Cough
Nervous disease
Rheumatic fever
Serious injuries
If any of the above are YES, include approximate date / description:
Student’s Signature (if older than 18 years)
Date ___________
Signature of Parent and/or Guardian _______________________________Witness_________________