Student Health Record Siena College
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2
3
4Page 1
Please return completed form to:
Siena College Health Service 515 Loudon Road, Loudonville, NY 12211
SIENA COLLEGE HEALTH RECORD
Please complete pages 1 & 2, and review the information with your health care provider prior to your physical exam on page 3.
_______________________________________________________________________________________________________________ /______/_________
LAST NAME (PRINT)
FIRST NAME
MIDDLE
DATE OF BIRTH
901
______________________________________________________________________________________________________
______________________
HOME ADDRESS (NUMBER AND STREET)
CITY OR TOWN
STATE
ZIP CODE
SID#
______________________________________________________________________________________________________________________________
(AREA CODE) HOME TEL. NUMBER
(AREA CODE) CELL NUMBER
______________________________________________________________________________________________________________________________
If the campus was closed due to emergency, who would you call? EMERGENCY CONTACT: NAME/RELATIONSHIP
(AREA CODE) CELL NUMBER
______________________________________________________________________________________________________________________________
If the campus was closed due to emergency, where would you go?
EMERGENCY CONTACT ADDRESS
(AREA CODE) TEL. NUMBER
______________________________________________________________________________________________________________________________
LIST OF ALL COLLEGES YOU HAVE ATTENDED AND DATES
CITIZENSHIP
MARITAL STATUS (circle one) S M OTHER / / MALE___ FEMALE____ // ______________________________
CLASS YOU ARE ENTERING
FAMILY HISTORY
Have any of your
relatives had any of the
following?
Age
State of
Occupation
Age at
Cause of
YES
NO
Relationship
Health
Death
Death
Father
Tuberculosis
Mother
Diabetes
Kidney Disease
Brothers
Heart Disease
Arthritis
Stomach Disease
Sisters
Asthma, Hay Fever
Epilepsy, Seizures
Cancer
PERSONAL HISTORY: PLEASE ANSWER ALL QUESTIONS
HAVE YOU HAD?
YES
NO
HAVE YOU HAD?
YES
NO
Chicken Pox
Inflammatory Bowel Disease
Ear Problems/Hearing Loss
Kidney/Bladder Infection
Eye Problems
Sexually Transmitted Disease
Sinusitis
Menstrual Disorder
Recurrent Headaches
Depression
Head Injury with unconsciousness
Anxiety Disorder
Recurrent Strep Throat
Seizure Disorder
Thyroid Disorder
Cancer
Asthma
Diabetes
Pneumonia
Sickle Cell/ Sickle Cell Trait
Heart Murmur
Anemia
Mitral Valve Prolapse
Joint Injury
High Blood Pressure
Back Problems
Stomach Ulcers
Mononucleosis
Hepatitis (A, B, C)
Other
Irritable Bowel
PROVIDE COMMENTS ON ALL “YES” ANSWERS IN SPACE BELOW:
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