Medical History : Welcome Packet Forms : Student Life

Medical History Questionnaire

All students must complete this form and return it to the Student Health Center by December 10, 2012.

health_center@redlands.edu • 1200 E. Colton Ave. Redlands, CA. 92373-0999
Tele: (909) 748-8021 • Fax: (909) 335-5117

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2012-2013

First Name:

Middle:

Last Name:

Gender:

Student ID:

Date of Birth:

Country of Birth:

Citizenship:

Address

Number and Street:

City:

State/Province:

Zip/Postal Code:

Allergies

Medication Allergies:

Food Allergies:

Other Allergies:

Emergency Contact

First Name:

Middle:

Last Name:

Relationship to Student:

Day Phone:

Evening Phone:

Other Way to Contact (pager, cell phone, etc.):

Personal & Family Health History

Height:

Weight:

Are you currently under medical treatment?:

Yes No

Why?:

This field is not required since you selected "No" above.

Name of Physician:

Physician's Phone Number:

Do you take mediation daily?:

Yes No

If yes, please list (include birth control, ADD medication, antidepressants):

This field is not required since you selected "No" above.

Have you ever had surgery?:

Yes No

If yes, please describe, include dates:

This field is not required since you selected "No" above.

Please indicate which of the following conditions/diseases you or your family members have or have had previously. Please also indicate who in your family has had the conditions/diseases.

ADD/ADHD:	Student Past Student Present Family Member Past Family Member Present
Alcohol dependency:	Student Past Student Present Family Member Past Family Member Present
Allergic rhinitis:	Student Past Student Present Family Member Past Family Member Present
Anemia:	Student Past Student Present Family Member Past Family Member Present
Anxiety:	Student Past Student Present Family Member Past Family Member Present
Arthritis:	Student Past Student Present Family Member Past Family Member Present
Asthma:	Student Past Student Present Family Member Past Family Member Present
Back trouble:	Student Past Student Present Family Member Past Family Member Present
Bladder/Kidney infection:	Student Past Student Present Family Member Past Family Member Present
Bleeding disorder:	Student Past Student Present Family Member Past Family Member Present
Blood transfusion:	Student Past Student Present Family Member Past Family Member Present
Brochitis:	Student Past Student Present Family Member Past Family Member Present
Cancer:	Student Past Student Present Family Member Past Family Member Present
Chronic inflammatory bowel disorder:	Student Past Student Present Family Member Past Family Member Present
Chicken pox:	Student Past Student Present Family Member Past Family Member Present
Concussion:	Student Past Student Present Family Member Past Family Member Present
Depression:	Student Past Student Present Family Member Past Family Member Present
Diabetes:	Student Past Student Present Family Member Past Family Member Present
Drug dependency:	Student Past Student Present Family Member Past Family Member Present
Eating disorder:	Student Past Student Present Family Member Past Family Member Present
Emphysema:	Student Past Student Present Family Member Past Family Member Present
Epilepsy:	Student Past Student Present Family Member Past Family Member Present
Excessive fatigue:	Student Past Student Present Family Member Past Family Member Present
Heart disease:	Student Past Student Present Family Member Past Family Member Present
Hepatitis:	Student Past Student Present Family Member Past Family Member Present
Hernia:	Student Past Student Present Family Member Past Family Member Present
High blood pressure:	Student Past Student Present Family Member Past Family Member Present
Infectious mononucleosis:	Student Past Student Present Family Member Past Family Member Present
Malaria:	Student Past Student Present Family Member Past Family Member Present
Menengitis:	Student Past Student Present Family Member Past Family Member Present
Migraines:	Student Past Student Present Family Member Past Family Member Present
Obesity:	Student Past Student Present Family Member Past Family Member Present
Pneumonia:	Student Past Student Present Family Member Past Family Member Present
Sexually transmitted infections:	Student Past Student Present Family Member Past Family Member Present
Sinusitis:	Student Past Student Present Family Member Past Family Member Present
Thyroid problems:	Student Past Student Present Family Member Past Family Member Present
Tonsillitis:	Student Past Student Present Family Member Past Family Member Present
Tuberculosis or exposure to TB:	Student Past Student Present Family Member Past Family Member Present
Ulcer:	Student Past Student Present Family Member Past Family Member Present
Vaginitis:	Student Past Student Present Family Member Past Family Member Present
Other:	Student Past Student Present Family Member Past Family Member Present

Please indicate whether or not you:

Are you a consistent seat belt user?:

Yes No

Are concerned about your weight?:

Yes No

If yes, list methods of weight loss or gain:

This field is not required since you selected "No" above.

Are a cigarette smoker?:

Yes No

If yes, packs per day:

This field is not required since you selected "No" above.

If yes, years smoking:

This field is not required since you selected "No" above.

Are an alcohol consumer?:

Yes No

If yes, drinks per day:

This field is not required since you selected "No" above.

If yes, drinks per week:

This field is not required since you selected "No" above.

If yes, drinks per month:

This field is not required since you selected "No" above.

Are marijuana user?:

Yes No

If yes, how much per day:

This field is not required since you selected "No" above.

If yes, how much per week:

This field is not required since you selected "No" above.

If yes, how much per month:

This field is not required since you selected "No" above.

Is there any other information about your medical history or current medical needs we should know?

Other medical history:

Signature

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Medical History Questionnaire