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: 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.