MEDICAL HISTORY FORM

CHECK APPROPRIATE BOXES         Sport 
NURSING PROGRAM
Last Name   First Name   M.I.        Student ID  
Date of Birth   SSN# Entering as a:
Home Address   City State
Resident Status
Home Phone Cell Phone Email Address  
 
Emergency Contact's Name Home Phone
Home Address Cell Phone
Parent Consent for Emergency Care for Students Under 18 Years of Age
In Case of an accident or emergency where there is not time to contact the parents, the University is hereby given authority to make decisions for treatment or surgery.
Parent(s) or Guardian(s) Signature:
Family History
 Family MemberNameAgeState of HealthOccupationAge/Cause of Death
Add
What relative has had:
Diabetes Kidney Disease Cancer
Asthma, Hay Fever Heart Disease Mental Illness
High Blood Pressure Seizures, Convulsions Tuberculosis
Personal History (Please answer all questions.)
Have you had...
Scarlet Fever Diabetes Recurrent Headaches Back Trouble
Measles Cancer Weakness/Paralysis Bone Fractures
German Measles Arthritis Gum/Tooth Trouble Joint Disease/Injury
Mumps Tumor, Cyst Ear Eye Nose Throat Dizziness/Fainting
Chicken Pox Convulsions/Seizures Mononucleosis Difficulty Sleeping
Malaria Pneumonia/Bronchitis Shortness of Breath Skin Trouble
Tuberculosis High or Low Blood Pressure Chronic Cough Surgery (describe below)
Hay Fever/Asthma Stomach/Intestinal Trouble Emotional Problems Eating Disorder
Rheumatic Fever Head Injury Smoker Kidney/Urinary Trouble
Heart Murmur Head Injury with Unconsciousness
Please explain any "yes" responses
ALLERGIES: Describe known allergies or drug sensitivities
MEDICATION: Prescription, over the counter, supplements, or performance agents you are taking
Have you had any illness or surgery which required hospitalization? Explain
Have you consulted or been treated by clinic, physician, or other practitioners
within the past five years?
Explain
If so, have any of your activities been restricted in the past five years? Explain
IMMUNIZATION INFORMATION
• Immunization records are encouraged, please submit to campus nurse upon arrival to campus - please make sure the student's name is on the copy.
• If you received any immunizations while attending BCU, please submit a copy to the Health Office.
STATE LAW REQUIRES the following information be submitted for those living in the residence halls.
Meningococcal immunization    Date Received
Have you recieved information on meningococcal disease and benefits of the vaccine
I Acknowledge that Briar Cliff University Abides by the Protected Health Information Privacy Act.
(A copy of the protected Health Information Act is available in the Health Office.) A signature is required prior to th erelease of any health information. I hereby authorize Briar Cliff University to release verbally or by documentation from the medical record:
 Briar Cliff University Athletic Department (a computerized copy of the Medial History Form is available for the trainer)
 Briar Cliff University Nursing Department (a computerized copy of the Medical History Form is available for the Dept. of Nursing)
 (Names) of my parents and/or guardian
 Briar Cliff University Insructors or Professors in the event of illness
I may withdraw this consent at any time by providing written notice, except that disclosure made is good faith, in reliance on this consent, has already occurred. I hereby authorize the release of information as indicated above.
PRINT NAME             DATE
Submit
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