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

2012-2013

 
 
 
 
 
 
 
Allergies
Emergency Contact
 
 
 
 
 
Personal & Family Health History
 
 
This field is not required since you selected "No" above.  
This field is not required since you selected "No" above.  
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:
Alcohol dependency:
Allergic rhinitis:
Anemia:
Anxiety:
Arthritis:
Asthma:
Back trouble:
Bladder/Kidney infection:
Bleeding disorder:
Blood transfusion:
Brochitis:
Cancer:
Chronic inflammatory bowel disorder:
Chicken pox:
Concussion:
Depression:
Diabetes:
Drug dependency:
Eating disorder:
Emphysema:
Epilepsy:
Excessive fatigue:
Heart disease:
Hepatitis:
Hernia:
High blood pressure:
Infectious mononucleosis:
Malaria:
Menengitis:
Migraines:
Obesity:
Pneumonia:
Sexually transmitted infections:
Sinusitis:
Thyroid problems:
Tonsillitis:
Tuberculosis or exposure to TB:
Ulcer:
Vaginitis:
Other:
Please indicate whether or not you:
Are you a consistent seat belt user?:
This field is not required since you selected "No" above.  
This field is not required since you selected "No" above.  
This field is not required since you selected "No" above.  
This field is not required since you selected "No" above.  
This field is not required since you selected "No" above.  
This field is not required since you selected "No" above.  
This field is not required since you selected "No" above.  
This field is not required since you selected "No" above.  
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?
Signature
You are under 18 and must print this form below.
 

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