Medical History Form Student Name(Required) First Last Student Email Date of Birth(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Medical HistoryAllergies(Required)List all allergies (medications, food, insects etc.) and the reactions.Do you smoke or use any tobacco products? Yes No Do you drink alcohol? Yes No Medical Conditions ADHD Alcohol/Drug Dependency Ambulatory Impairment Anemia, Blood Disease Anxiety/Depression Arthritis, Joint/Bone Disease Asperger Syndrome Asthma Autism Back/Neck Pain/Condition Bipolar Disorder Blood Clots, Phlebitis Cancer Chicken Pox Crohn's Disease Diabetes Type 1 Diabetes Type 2 Digestive Disorder Epilepsy, Seizures Fainting Spells Head Injury Hearing Impairment Heart Murmur, Disease Hemophilia Hepatitis High Blood Pressure Hypoglycemia (Low blood sugar) Kidney Disease Low Blood Pressure Lyme Disease Malaria Migraines Psychiatric Conditions Rheumatic Fever Sickle Cell Disease Schizophrenia Thyroid Disease Tuberculosis Ulcerative Colitis Visual Impairment Please check any conditions that you have been or are currently being treated for:Other medical conditionsList any other medical condition you have that is not on this list.Doctor InformationDoctor's Name(Required) Dr.MissMr.Mrs.Ms.Prof.Rev. Prefix First Last Office Phone Number(Required)Specialty Doctor's Name Dr.MissMr.Mrs.Ms.Prof.Rev. Prefix First Last Office Phone NumberSpecialty Current MedicationsMedications List(Required)Please list all medications taken by the student and the frequency with which they are taken.CAPTCHA Δ
