Health History

First Name: (required)

Last Name: (required)

Date of Birth:

Mailing Address:

Phone Number:

Emergency Contact Name:

Emergency Contact Phone Number:

Emergency Contact Relationship:

Has any member of your immediately family (parents, grandparents, siblings) had any of the following:
High Blood PressureStrokeCancerHeart DiseaseHigh CholesterolDiabetesThyroid DisorderRespiratory DiseaseAlcohol/Drug AbusePsychiatric IllnessSuicide

Other family medical history:

Do you now or have you ever had any of the following:
High blood pressurePain/pressure in chestHeart diseaseAsthmaRespiratory DiseasePneumoniaShortness of breathTuberculosisDizziness/fainting spellsMigraine headachesSevere head injury/concussionBack or neck injury/painBroken bonesJoint painAlcohol/drug problemsEating disorderDepression/anxietySelf injurious behaviorLearning disability/ADD/ADHDSleep problems

Other Personal Medical History:

Have you ever been hospitalized?
YesNo

If yes, please explain below:

Have you ever had any surgeries?
YesNo

If yes, please explain below:

Do you have any allergies, including medication allergies?
YesNo

If yes, please explain below:

Do you have any food allergies?
YesNo

If yes, please explain below:

Are you currently taking any medications?
YesNo

Are you currently being treated by a health care professional?
YesNo

I hereby authorize the faculty and staff of Alaska Christian College to give emergency care to myself and to determine the need for a doctor's service when necessary: Please draw your signature into the box below.

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