Information you provide will not be used to influence your situation at the University; it will be used, however, solely as an aid to providing necessary health care while you are a student. This information is strictly for the use of the Health Services and will not be released to anyone without your knowledge or consent.

First Name*:		Last Name*:		Gender: Male Female
Birth Date*:	-Month- Jan Feb March April May June July Aug Sept Oct Nov Dec -Day- 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 -Year- 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936
Address*:
City/Town*:		State/Province*:		Zip/Postal Code*:
Country*:			Email*:

Have any of your relatives ever had any of the following:
Tuberculosis:	Yes No	Relationship:
Diabetes:	Yes No	Relationship:
Kidney Disease:	Yes No	Relationship:
Heart Disease:	Yes No	Relationship:
Arthritis:	Yes No	Relationship:
Stomach Disease:	Yes No	Relationship:
Asthma/Hay Fever:	Yes No	Relationship:
Epilepsy, Convulsions:	Yes No	Relationship:

Have you ever had any of the following:
Scarlet Fever:	Yes No	Insomnia:	Yes No
Measles:	Yes No	Frequent Anxiety:	Yes No
German Measles:	Yes No	Frequent Depression:	Yes No
Mumps:	Yes No	Worry/Nervousness:	Yes No
Chicken Pox:	Yes No	Recurrent Headaches:	Yes No
Malaria:	Yes No	Recurrent Colds:	Yes No
Gum or Tooth Trouble:	Yes No	Head Injury/ Unconsciousness:	Yes No
Sinusitis:	Yes No	Eye Trouble:	Yes No
Surgery (explain below):	Yes No	Allergies (explain below):	Yes No
Ear/Nose/Throat Trouble:	Yes No	Pain/Pressure in the Chest:	Yes No
Chronic Cough:	Yes No	Heart Palpitations:	Yes No
High/Low Blood Pressure:	Yes No	Rheumatic Heart Fever/Heart Murmur:	Yes No
Weakness/Paralysis:	Yes No	Venereal Disease:	Yes No
"Trick" Knee/ Shoulder, etc.:	Yes No	Back Problems:	Yes No
Tumor/Cancer/Cyst:	Yes No	Jaundice:	Yes No
Gallbladder/Gallstones:	Yes No	Recurrent Diarhea:	Yes No
Rupture/Hernia:	Yes No	Recent Weight Gain/Loss:	Yes No
Dizziness/Fainting:	Yes No	Disease/Injury of Joints:	Yes No
Frequent Urination:	Yes No	Stomach/Intestinal Trouble:	Yes No
A. Has your physical activity been restricted during the past five years? If yes, give reasons and duration below. Yes No
B. Have you had difficulty with school, studies, or teachers? If yes, give details below. Yes No
C. Have you received treatment or counseling for a nervous condition, personality, or character disorder, or emotional problem? If yes, give details below. Yes No
D. Have you ever had any illness or injury and been hospitalized other than already noted? If yes, please explain. Yes No
E. Have you consulted or been treated by clinics, physicians, healers, or other practitioners within the past five years? If other than routine checkups, please explain. Yes No
F. Have you ever been rejected for or discharged from military service because of physical, emotional, or other reasons? If yes, please explain. Yes No
Explanations:
For Females Only:
Irregular Periods:	Yes No	Severe Cramps:	Yes No
Excessive Flow:	Yes No

Please verify that all required fields have been filled and that all information is to your knowledge accurate. Once you have looked over the form for accuracy, please submit this form.