SDSU Student Health Clinic & Counseling Services
South Dakota State University, Box 2818, Wellness Center, 1440 N. Campus Dr., Brookings, S.D. 57007
(605) 688-4157 Fax (605) 688-4032
Health History Form
PLEASE COMPLETE FORM IN INK
Name____________________________________________________________________ Gender
Last
First
□F □M
Middle
ID No. ____________________ Date of Birth _____________ Country of Citizenship ___________________
□WHITE □AMERICAN INDIAN □BLACK □ASIAN □PACIFIC ISLANDER Check one: HISPANIC-- □YES □NO
Entrance date to South Dakota State University □ Fall □ Spring □ Summer
Year __________________
Phone Number ______________________________ □ Land Line □ Cell -- Cell Carrier _____________________
Check one or more:
(For text messages)
Local Address_________________________________ City _______________________ State ________ Zip _________
Please check all the ways we may leave a message for you:
Cell Voice Mail
Text Message
E-mail — E-mail address ________________________________________________________
□
□
□
Emergency Data -- In an emergency, call:
Name ___________________________________________________
Home Phone ____________________________
□ Parent □ Guardian □ Spouse
Address _________________________________________
(Street Address)
Work Phone _____________________________
_________________________________________
(City, State, Zip Code)
Personal Health History
1. Allergies: Have you ever had an allergic reaction?
If yes, list any allergies & reactions to:
□ Yes □ No
Medications ___________________________________________________________________________
Foods ________________________________________________________________________________
Other (latex, bee/wasp stings, seasonal, etc.) _________________________________________________
2. Current medications (prescription or non-prescription—example-vitamins, birth control pills, etc.):
______________________________________________________________________________________________
□
□
3. Have you ever been hospitalized?
Yes
No
If yes, describe the reason(s) and date or your age at the time:________________________________________
__________________________________________________________________________________________________________
4. Surgeries (please include date or your age at the time):
_________________________________________________________________________________________________________
Family History: Have any close relatives (Parents, siblings) ever had any of the following?
___ Allergies
___ Asthma
___ Blood or clotting disorders
___ Cancer
___ Depression/Anxiety or other psychiatric
illness
___ Diabetes
___ Family History of Sudden Cardiac Death
(age 50 or younger)
___ Heart Disease
___ Hereditary Disease
___ High Blood Pressure
□
Adopted—Family History unknown
___ High cholesterol
___ Stroke
___ Thyroid Disease
___ Tuberculosis
___ Other serious illness
Explain any items checked ______________________________________________________________________________________
_____________________________________________________________________________________________________________
List any close relatives (Parents, siblings) who have died. Please list Age at death, Relationship, Cause of Death
_____________________________________________________________________________________________________________
PLEASE COMPLETE OTHER SIDE
10/2011
Personal Disease History: Have YOU ever had any of the following:
GENERAL
Y
N
RESPIRATORY
Chronic/Unusual Fatigue
Asthma
Mononucleosis
EYES
Glasses or contacts
Chronic cough (over 1 month)
Tuberculosis (TB) or positive
PPD
Shortness of Breath
CARDIOVASCULAR
High Blood Pressure
Heart Disease (murmur,
palpitations, etc.)
High Cholesterol
Blood clots or vein problems
Rapid or irregular pulse
Severe chest pain or pressure
GASTROINTESTINAL
Gall Bladder disease
Frequent diarrhea or
constipation
Reflux or Ulcer
Blood in stool
Hernia
Vision or eye problems
Hepatitis/Jaundice
Eating Disorder
Cancer
HIV Infection
Chicken Pox
Recent Weight Loss or Gain
Over 10 pounds
Malaria
SKIN
Severe acne or skin disorder
New or changing moles
Chronic skin problems (psoriasis, etc)
METABOLIC & ENDOCRINE
Diabetes
Thyroid disease
EARS, NOSE, SINUSES, THROAT
& NECK
Environmental Allergies (Hay Fever,
grasses, molds)
Ear or hearing problems
Frequent sinusitis
Dental problems or TMJ
GYNECOLOGICAL
Abnormal pap smear
Y
N
MUSCULOSKELETAL
Orthopedic Problems
(e.g. knee, back, ankle, etc.)
Arthritis
Y
Fractures
NEUROLOGICAL
Convulsions or seizures
Head injury or loss of consciousness
Severe or recurrent headaches
Dizziness or fainting
HEMATOLOGICAL
Abnormal bleeding tendency
Anemia
MENTAL HEALTH
Depression
Anxiety
GENITO-URINARY
Urinary Tract Infections
Kidney problems
Problems with testes, scrotum,
prostate
Sexually Transmitted Infection
(Chlamydia, Gonorrhea,
Syphilis, genital herpes,
genital warts/HPV
OTHER DISEASES
Breast Mass
Abnormal uterine bleeding
Irregular Menses
Please explain any “yes” answers:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Any other health conditions/concerns not previously mentioned? ____________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
The above information is accurate to the best of my knowledge.
Patient’s Signature:____________________________________________ Date:____________________________
==============================================FOR CLINIC USE ONLY===========================================
Provider: I have reviewed and updated this information:
Signature & Date: ___________________________Signature & Date: _________________________Signature & Date: _____________________
Signature & Date: ___________________________Signature & Date: _________________________Signature & Date: _____________________
Signature & Date: ___________________________Signature & Date: _________________________Signature & Date: _____________________
Signature & Date: ___________________________Signature & Date: _________________________Signature & Date: _____________________
10/2011
N