health forms HEALTH HISTORY To be completed by STUDENT COMPLETION

							health forms
                                                                                                                                                               O
                                                                                                                                                               X
 HEALTH HISTORY To be completed by STUDENT                                                                                                                     Y
 COMPLETION OF THESE FORMS IS A REQUIREMENT FOR CLASS REGISTRATION. The forms need to be in
 the Health Center Office three weeks prior to the beginning of school. Class enrollment will be jeopardized if health
 information is incomplete. NOTE: All medical information is confidential. However, we reserve the right to discuss
 immunization matters with parents unless a written request not to do so is provided.

  LAST NAME (PRINT), FIRST, MIDDLE                                                      GENDER:          MARTIAL STATUS:
                                                                                           M       F         S      M           D         W
  HOME ADDRESS                                                                                           DATE OF BIRTH


  HOME CITY, STATE, ZIP                                                                                  ENTERING OXY AS A:
                                                                                                             Fr.      So.           Jr.       Sr.   Graduate
  E-MAIL ADDRESS                                                                                         CELL PHONE
                                                                                                         (                  )

 In Case Of Emergency, Contact:
  LAST NAME (PRINT), FIRST, MIDDLE                                     RELATIONSHIP                      HOME PHONE

                                                                                                         (                  )
  HOME ADDRESS                                                                                           BUSINESS PHONE
                                                                                                         (                  )
  E-MAIL ADDRESS                                                                                         CELL PHONE
                                                                                                         (                  )

 Family Background
 Has anyone in your immediate family had any of the following?
                                                        Yes   No                         Explanation – relationship and dates

  Cancer (please specify type)
  Diabetes
  High Blood Pressure
  Thyroid Disease
  Heart Attack before age 50 in immediate
  Family
  Stroke
  Mental Illness (Including depression, anxiety)
  Alcohol or Drug Use
  Other



 ALLERGIES:      Yes                 No (Please list any allergies to medications, foods, insect stings, pollen, or other
 environmental factors)


 I take allergy shots (specify allergens and frequency that medications are taken):


 I take the following medication(s) routinely:



                                                                                                                                                    (continued next page)
health forms
                                                                                                                                O
                                                                                                                                X
 HEALTH HISTORY Continued                                                                                                       Y
 MEDICAL OR HEALTH CONCERNS – Use box to the left to indicate the age at which you had the following condition(s).
   Check this box if NONE apply.

       ADD/ADHD                        Chicken Pox                    Scarlet Fever                 Surgery (specify)
       Alcohol/Drug Use                German Measles                 Rheumatism or Arthritis
       Anxiety                         Infectious Mononucleosis       Colitis/Crohn’s Disease
       Depression                      Malaria                        Irritable Bowel Syndrome      Fracture (specify)
       Eating Disorder                 Measles                        Jaundice
       Suicide Attempt                 Mumps                          Stomach or Duodenal Ulcer
       Convulsions/Seizures            Rubella                        Urinary Tract Infection       Heart Condition (specify)
       Migraine                        Positive TB Test               Skin Disorders
       Ear, Nose and Throat Problems   Tuberculosis                   GERD
       Hay Fever                       Asthma                         Chronic Headache              Other (specify)
       Diabetes                        Pneumonia


 A. Do you have an illness or condition, not listed above, for which you are now being treated? If yes, specify:



 B. Have you been under care of a healthcare provider (medical/mental health) during the past year? If yes, specify:



 C. Do you have chronic or congenital conditions? If yes, describe:



 D. List date(s) and reason(s) for any hospitalizations:




    I would like someone from the Counseling Center to contact me about mental health resources on campus.




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health forms
                                                                                                                             O
                                                                                                                             X
 HEALTH HISTORY Continued                                                                                                    Y
 Insurance Information
 Attach a copy of the front and back of your insurance card here:




                                     front                                                back




 I plan to purchase the School Health Insurance:                Yes   No



 Statement Of Authorization
 NOTE: The Financial Responsibility and Consent to Treatment must be signed by both the student and parent.

 I hereby accept financial responsibility for the expense of health care services, which are rendered to the aforementioned
 student by Emmons Health Center or such other health care provider as Emmons Health Center shall determine necessary
 or desirable.

 I hereby give permission for the aforementioned student to receive general non-surgical medical treatment from
 Emmons Health Center or such other health care provider as Emmons Health Center shall determine necessary
 or desirable.

 SIGNATURE OF STUDENT (REQUIRED)                                                             DATE



 SIGNATURE OF LEGAL RESPONSIBLE PARENT OR GUARDIAN (REQUIRED)                                DATE