LAST NAME (Print) FIRST NAME MIDDLE SEX M ( ) F Diabetes. Brothers. Kidney Disease. Heart Disease. Arthritis. Sisters. Stomach Disease. Asthma …
Report of Medical History
Waynesburg College Student Health Service
p 1 of 4
Waynesburg Campus
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_________________________________ Other Campus
LAST NAME Print FIRST
NAME
MIDDLE SEX M
F
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HOME ADDRESS Number and Street
CITY OR TOWN STATE
ZIP CODE DATE OF BIRTH
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NAME RELATIONSHIP AND ADDRESS OF NEXT OF KIN
HOME TELEPHONE NUMBER
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NEXT OF KINS BUSINESS ADDRESS
BUSINESS TELEPHONE
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LIST OF COLLEGES YOU HAVE ATTENDED, ADDRESSES AND DATES
CITIZENSHIP
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______________S M OTHER ___________________________
ARE YOU A VETERAN? BRANCH AND LENGTH OF SERVICE
MARITAL STATUS
MONTH/YEAR OF ENTERING
THIS SCHOOL
FAMILY HISTORY
Have you or any of your relatives ever had any of
the following?
| | |State|
| |Age|of |
| | |Healt|
| | |h |
|A Has your physical activity been restricted during the past five | | |
|years? Give reasons and durations
| | |
|B Have you had difficulty with school, studies, or teachers? Give | | |
|details | | |
|C Have you received treatment or counseling for a nervous condition, | | |
|personality or character disorder or emotional problem? Give Details | | |
|D Have you had any illness or injury or been hospitalized other than | | |
|noted? Give details | | |
|E Have you consulted or been treated by clinics, physicians, healers | | |
|or other practitioners within the past five years? Other than routine | | |
|checkups? | | |
|F Have you been rejected for or discharged from military service | | |
|because of physical, emotional, or other reasons? If so, give reasons | | |
|G Do you have any question in regard to your health, family history or | | |
|other matters that you would like to discuss with a member of the staff? | | |
|H Are you taking any medicine or drugs? If so - what?
| | |
|I Do you have any dietary problems necessitating special diets? | | |
|J Do you need any auxiliary aids or services identified in the | | |
|Americans with Disabilities Act to attend this school? | | |
REMARKS OR ADDITIONAL INFORMATION Use additional sheet if necessary
Student Signature_______________________Date____________
