Health History Form

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Gender *
Emergency Notification
Please include parents, guardian, or spouse (parent information prefered). The first person listed will be the one contacted first.
Alternate Emergency Notification 
Student Medical History
Have you had or currently have? *
 YesNo
Anemia
Anxiety
Asthma
Cancer
Back Problems
Depression
Diabetes
Ear, Nose, and Throat Disease
Eating Disorder
Eye Disorder
Gallbladder Disease
Gastrointestinal Disease/Disorder
Genetics
Headaches/Migraines
Head Injury/Concussions
Heart Disease
Heart Murmur
Have you had or currently have? *
 YesNo
Hemophilia
Hepatitis
Hernia
High Blood Pressure
HIV/Aids
Kidney Disease
Menstrual Irregularity (females)
Mononucleosis
PTSD
Rheumatic Fever
Seasonal Allergies
Seizure Disorder
Sickle Cell Trait
Thyroid Disorder
Urinary Tract Infections
ADHD/ADD
Learning Disability
Do you have an on-going chronic illness? *
Do you wear glasses *
Do you wear contacts? *
Do you have a latex allergy? *
Do you take any medication regularly (prescription, non-prescription, supplements, etc)? *
Are you allergic to any medication or have had any adverse reactions to any drugs (prescription, non-prescription, supplements, etc)? *
Do you have a permanent medical disability? *
Would this disability affect your college experience? *
Do you have any intellectual, learning, or academic disorders? *
Do you have any physical limitations or emotional disorders? *
Do you have any dietary restrictions? *
I also certify that the information is complete and accurate to the best of my knowledge. I understand that in the event of illness or injury I am authorizing Health Services or a designated individual to give or obtain treatment. I will be financially responsible for any costs incurred.
Signature of Student *
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If student is under 18, a parent’s or guardian’s signature below gives the Director of Health Services, Deans, or other designated individuals permission to give or obtain treatment for their son or daughter. I understand I will be financially responsible for any costs incurred.
Signature of Parent/Guardian
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The information contained in this form is restricted for use by the Health Services Office and limited personnel at Faith Baptist Bible College and will not be released without the student’s knowledge or consent.
©KristyStodola