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Student Health Form: General Information

This student health form collects information about a student's general health history, past medical conditions, current medications, immunization records, and provides consent for treatment at the university's student health services. It requests details on respiratory, cardiovascular, blood, musculoskeletal, endocrine, gastrointestinal, genitourinary, neurological, psychological, and infectious conditions. It also asks about allergies, current medications, reasons why a student cannot exercise, and any health questions. Required immunizations include MMR, varicella, tetanus within 10 years. Recommended immunizations include meningitis, hepatitis B, and TB skin test. The student and parent/guardian must provide consent for treatment.

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73 views1 page

Student Health Form: General Information

This student health form collects information about a student's general health history, past medical conditions, current medications, immunization records, and provides consent for treatment at the university's student health services. It requests details on respiratory, cardiovascular, blood, musculoskeletal, endocrine, gastrointestinal, genitourinary, neurological, psychological, and infectious conditions. It also asks about allergies, current medications, reasons why a student cannot exercise, and any health questions. Required immunizations include MMR, varicella, tetanus within 10 years. Recommended immunizations include meningitis, hepatitis B, and TB skin test. The student and parent/guardian must provide consent for treatment.

Uploaded by

reza329329
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Student Health Form

GENERAL INFORMATION
Name

Birth Date

Home Address
Gender:

Number & Street, P.O. Box or Apt. #

Male

Female

City

State

Zip

T#

Phone Number (
Marital Status:

/
)

Emergency Contact Information: Name

Phone Number (

Family Physician: Name

Phone Number (

PAST MEDICAL HISTORY

Have you had any of the following conditions or related conditions? If "yes," please describe. List the frequency and severity, medications or surgeries.
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

No | Respiratory System: hay fever, asthma, tuberculosis, sinus problems?


No | Cardiovascular: palpitations, high/low blood pressure, chest pain, heart murmur, heart disease?
No | Blood Diseases Disorders: anemia, bleeding tendencies?
No | Muscle-Skeletal: "trick" knee, back problems, broken bones, recurrent sprains/tendonitis, deformities, arthritis?
No | Endocrine: thyroid, diabetes, adrenal?
No | Gastro-intestinal: ulcer, gallbladder, diarrhea, constipation?
No | Genitourinary: menstrual problem, kidney/bladder problems, prostatitis, vaginal infections?
No | Neurological: seizures, hearing problems, head injury with unconsciousness?
No | Psychological: anxiety, depression, other emotional disorders?
No | Infections: rheumatic fever, malaria, hepatitis?
No | Surgeries: tonsillectomy, appendectomy, hernia repair, other?
No | Tumor/cyst/cancer?

CURRENT MEDICAL HISTORY


Yes
Yes
Yes
Yes

No | Allergies: medicines, bee stings, other? If "yes," please list:


No | Are you currently taking any prescribed drugs or medical treatment (including birth control pills)?
No | Do you know any reasons why you should not participate in normal physical exercise?
No | Do you have any questions regarding your health or other matters you'd like to discuss with the Health Services Staff?

IMMUNIZATION REQUIRED (Requires signature or stamp from health care provider below or official document attached)
Vaccines
Dates
Signature
MMR (measles, mumps, rubella)
1.
2.
Varicella (chicken pox)
1.
2.
Or documentation of disease by medical personnel.
IMMUNIZATIONS RECOMMENDED (Requires signature or stamp from health care provider below or official document attached)

Tetanus (within past 10 years)


Meningitis
Hepatitis B
TB Skin Test

Date given:

PERMISSION FOR TREATMENT AT TTU STUDENT HEALTH SERVICES


(If under 18, co-signed by parent or guardian)
Student signature

Date

Parent or guardian signature

Date

Please return to Tennessee Tech University, Student Health Services, Box 5096, Cookeville, TN 38505-0001, or fax to (931) 372-3848.

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