Student Medical History Form

Name *
Name
PERSONAL HISTORY
Please check if you have or have had any of the following:
Diseases and Disorders
Surgery
Allergies/sensitivities
Please list any habits you have, such as tobacco or alcohol use, and indicated how much/how often.
If you checked other for any of the above categories, please explain below.
FAMILY HISTORY
Please fill out your family history as it relates to the state of their health.
If deceased or if unknown, please write Not applicable.
If deceased or if unknown, please write Not applicable.
If deceased or if unknown, please write Not applicable.
If deceased or if unknown, please write Not applicable.
REVIEW OF PAST ILLNESSES OR SYMPTOMS
Please complete the following. Do not leave any questions blank.
If yes, please fill out the next section.
If yes, please fill out the next section.
If yes, please fill out the next section.
If yes, please fill out the next section.
If yes, please fill out the next section.
If yes, please fill out the next three questions.
If yes, please fill out the next section.
You will need to have a mental health professional or counselor fill out an additional form.
Date
Date