Seattle University Student Health Clinic
Health History Form
Name:
Date of Birth:
Last
First
MI
Birth Place:
Month Day Year
Have you had or do you have any of the following conditions: (please check items you are experiencing or have
experienced before and indicate the year of occurrence)
Problem
acne
eczema/psoriasis
fungal infections
concussion/head injury
epilepsy
migraine/headaches
dizziness/fainting
ear infection
eye or vision trouble
sinusitis
allergies/hayfever
tonsillitis
breast lump
asthma
pneumonia
bronchitis
tuberculosis
Year
Problem
positive TB test
congenital heart disease
heart murmur
high blood pressure
rheumatic fever
anemia
other blood disorders
bleeding problems
acid reflux
stomach ulcer
intestinal disorder
gallbladder trouble
hernia
hemorrhoids/fissures
recurrent diarrhea
recurrent vomiting
bladder infection
Year
Problem
kidney infection
kidney stone
liver disease
ovarian cyst
endometriosis
pelvic infection
sexually transmitted
disease:(chlamydia,
gonorrhea, herpes,
warts, other)
abnormal pap smear
testicular problems
high cholesterol
diabetes
thyroid disease
broken bones
arthritis/bursitis
Year
Problem
Year
bone/joint deformity
neck injury
back injury
recurrent back pain
knee injury
shoulder injury
ligament repair
depression
panic/anxiety attacks
sleep problem
ETOH/drug dependency
anorexia/bulimia
mononucleosis
hepatitis
malaria
tumor/cancer
chicken pox
Other serious illnesses or injuries not listed:
Are you receiving treatment for any of the problems noted above? If so please give details:
Have you ever had surgery? If so, when and why:
Have you ever been hospitalized? If so, when and why:
Have you ever received mental health counseling? If so, when and why:
Do you take any medications on a regular or intermittent basis? If so, what, why and how frequently:
___________________________________________________________________________________________________
Do you have any drug allergies? If so, what drug and what type of reaction:
Do you have any other allergies? (e.g. bee stings):
F a m il y Health Histor y:
heart attack
high cholesterol
high blood pressure
stroke
diabetes
Check any disease that has occurred to any blood relative
______
kidney disease
______
______
breast cancer
______
______
migraine
______
______
depression
______
______
cancer
______
glaucoma
arthritis
blood disorder
other
THIS IS A 2-SIDED FORM PLEASE COMPLETE SIDE 2
______
______
______
Social History:
Marital status: ____ single ____ married ____ partnered ____ divorced ____ separated ____ widowed
Number of children, age and sex
Academics: ____ Freshman _____ Sophomore _____ Junior _____ Senior _____ Graduate Program
Major: ________________________
Work/Occupation: ______________________
Living situation: _____ Campus housing _____ Off Campus
Do you smoke currently or have you ever smoked? _____ Yes _____ No
Cigarettes/day _____ Years smoked _____ When quit
Do you participate in intercollegiate sports? _____ Yes _____ No If so, what sport?
Do you have a daily exercise routine? If so, what do you participate in and how frequently?
How many meals per day do you eat?
What food groups do you eat? _____ Breads _____ Fruit _____ Vegetables _____ Meat/fish _____ Dairy
Do you currently, or have you ever had problems with eating disorders like anorexia or bulimia? _____ Yes _____ No
Do you drink caffeinated beverages? If so, how many cups/cans per day?
Do you drink alcoholic beverages? If so, what and how much per week?
Have you ever been concerned about the amount of alcoholic beverages you drink?
Do you have any body piercings or tattoos? _____ Yes _____ No If so, where?
Medical Provider comments:
Medical Provider signature: _____________________________________________________
Date
Patient Rights and Responsibilities
Patients have the right to:
1.
Change their primary health care providers if they choose.
2.
Have their personal privacy respected.
3.
Receive an explanation of their diagnosis, treatment, and prognosis.
4.
Know the names and positions of people involved in their care.
5.
Refuse treatment except where prohibited by law.
6.
Participate in all health care decisions.
7.
Full confidentiality of their medical records, released only with their authorization unless an exception applies and
disclosure is permissible or required.
8.
Review any medical records maintained by the SHC.
Patients have a responsibility:
1.
To provide accurate information about their past health history.
2.
To ask questions if explanations or instructions were net understood.
3.
To pay all charges that are billed to them.
4.
To complete an evaluation form regarding satisfaction with services received.
I have read the above Patient Rights and Responsibilities.
Signature: _______________________________________________________________
Date: