Medical Health History Form
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1
2Health History Form
st
Please complete and return by August 1
to:
Student Health Center
P.O. Box 65
Baldwin City, Kansas 66006
785.594.8409 Fax: 785.594.8314
•COPY OF IMMUNIZATION RECORD
PLEASE INCLUDE:
This form is kept on file in the Student Health Center as a permanent part of your health record. This form can be completed
online at
Student Information:
Name (please print): _______________________________________________________________________________
Date of Birth: ____________________________ Student Phone #: _________________________________________
SSN #: ________________________________
Date Entering Baker:
Fall
Spring
Year________
White
Black or African American
Native Hawaiian & other Pacific Islander
Race:
Asian
Hispanic or Latino
American Indian & Alaska Native
Other ______________
Gender:
Male
Female
Other______________
Father’s Name: _________________________________________________________ Phone: ____________________
Mother’s Name: _________________________________________________________ Phone: ____________________
Person to Call in an Emergency: ______________________________________________________________________
Phone: _________________________________ Relationship: _________________________________
Medical History:
Family History:
(place relationship in blank)
Alcohol/Drug Abuse __________________
Asthma ________________________
Cancer/Type _________________
Heart Disease ______________________
High Blood Pressure______________
Stroke ______________________
Seizures ___________________________
Tuberculosis ____________________
Diabetes ____________________
Death before 50 _____________________
Depression/Anxiety_______________
Other_______________________
Disease/Illness History:
Check all that you have now or have ever had:
❍ Alcoholism/Drug Addiction
❍ Digestive Tract Disease (ulcer, colitis)
❍ Mumps
❍ Anemia
❍ Gallbladder/Liver Disease
❍ Orthopedic Problems (knee, back)
❍ Anorexia/Bulimia
❍ Glaucoma
❍ Pneumonia
❍ Asthma
❍ HIV/AIDS
❍ Prolonged Depression or Anxiety
❍ Cancer
❍ Heart Disease (rheumatic fever, murmur)
❍ Severe Headache (migraine)
❍ Chicken Pox
❍ Hepatitis
❍ Sexually Transmitted Diseases
❍ Chronic Bronchitis
❍ High Blood Pressure
❍ Speech, Hearing, Vision Problems
❍ Chronic Skin Disease (eczema, psoriasis)
❍ Infectious Mononucleosis (mono)
❍ Thyroid or Endocrine Disturbance
❍ Convulsions, Seizures (epilepsy)
❍ Kidney or Bladder Disease
❍ Tonsillitis
❍ Dental Problems
❍ Malaria
❍ Tuberculosis
❍ Diabetes
❍ Measles
❍ Typhoid
Health Information:
Current/Chronic Health Concerns:________________________________________________________________________________
___________________________________________________________________________________________________________
Surgical History:______________________________________________________________________________________________
___________________________________________________________________________________________________________
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