MEDICAL HISTORY
Vinson Health Center
LAST NAME (PRINT)
FIRST
MIDDLE
SOCIAL SECURTY NUMBER (OR) MUSTANGS ID NUMBER
LOCAL ADDRESS (NUMBER AND STREET)
CITY
STATE
LOCAL CELL PHONE NUMBER
LOCAL PHONE NUMBER
ZIP CODE
DATE OF BIRTH
SEX/ETHNICITY
YOUR PREFERRED EMAIL ADDRESS
IN CASE OF EMERGENCY (USA ONLY)
RELATIONSHIP
IN CASE OF EMERGENCY ADDRESS (NUMBER, STREET, APT.)
CITY
HOME/CELL NUMBER (USA ONLY)
STATE
ZIP CODE
Have any of your relatives ever had any of the following?
Yes
No
Relationship
Yes
Tuberculosis
Arthritis
Diabetes
Stomach
Disease
Asthma, Hay
Fever
Epilepsy,
Convulsions
Kidney Disease
Heart Disease
No
Relationship
Personal History (PLEASE ANSWER ALL QUESTIONS) Comment on all positive answers in the space below or attach additional page
Have you had?
Yes
No
Have you had?
Yes
No
Have you had?
Yes
No
Have you had?
Scarlet fever
Frequent anxiety
Chronic cough
Venereal disease
Measles
Frequent depression
Palpitations (heart)
Albumin/Sugar in urine
German measles
Worry or Nervousness
High or Low Blood Pressure
Frequent Urination
Mumps
Recurrent Headache
Rheumatic Fever or Heart Murmur
Female Only
Chicken Pox
Recurrent Colds
Disease or Injury of Joints
Irregular Periods
Malaria
Trick Knee, Shoulder, etc.
Sever Cramps
Gum or tooth trouble
Head Injury with
Unconsciousness
Hay Fever, Asthma
Back Problems
Excessive Flow
Tuberculosis
Sinusitis
Tumor, Cancer, Cyst
Diabetes
Ear, eye, nose, throat
trouble
Surgery
Shortness of Breath
Pain/Pressure in Chest
Jaundice
Stomach or Intestinal Trouble
Are you Allergic to:
Gallbladder Trouble or Gallstones
Appendectomy
Penicillin
Recurrent Diarrhea
Tonsillectomy
Hernia Repair
Sulfonamides
Serum
Rupture, Hernia
Recent Gain or Loss of Weight
Other
Foods (which)
Dizziness, Fainting
Insomnia
Other
No
Yes
No
Comments:
Weakness, Paralysis
Yes
No
A.Has your physical activity been restricted during the past five years?
C.Do you take any prescription medication? If so, please list.
B.Have you received treatment or counseling for a nervous condiction, personality or
character disorder, or emotional problem? (Give Details)
D.Have you had any illness or injury or been hospitalized other than already noted? (Give
Details)
I acknowledge that the above information is correct.
Signed_______________________________________________________Date___________________________________
7/15
Yes
Report of Medical History
Vinson Health Center
To provide you with the best possible health care at the Vinson Health Center, we ask that you complete this
Medical History report. The information you furnish on the Medical History form is for use by the Vinson Health
Center and will not be released to anyone without your knowledge and consent.
Senate Bill 157 requires certain immunizations for specific classes of students. If you are enrolling in Health Related
courses, you must furnish proof of immunization.
Patient Rights
I have read and/or received a copy of my “Patient Rights”
(Initial) __________
Notice of Privacy Practices
I have read and/or received a copy of the “Notice of Privacy Practices”
(Initial) __________
Advanced Directive
(Living Will)
Do you have an Advanced Directive or Living Will?
If YES, please provide a copy for our records.
Y_____
For All Students:
By signing below, I verify that the information provided on this form is correct.
_____________________
DATE
Return to:
Vinson Health Center
Midwestern State University
3410 Taft Blvd.
Wichita Falls, Texas 76308-2099
_______________________________________
STUDENT SIGNATURE
(Please Complete Both Sides)
N_____