HEALTH HISTORY FORM

2 Health Center Drive
Athens, OH 45701
Tel: (740)593.1660 Fax: (740)593.0179
HEALTH HISTORY FORM
______________________________________________________________
_______________________________
Legal Name
Preferred Name
Last
______________________
Student PID Number
First
_____________
Date of Birth
Middle Initial
___________
Legal Sex
________________________________________________
Preferred Mailing Address
What was your sex assigned at birth?
______Female
Do you identify as transgender or transsexual?
_________________________
Preferred Contact Number
______Male
______Yes
_________________
_________________
Preferred Pronouns
Relationship Status
(ie. he/him, she/her, they/their)
____________________
OHIO E-mail
______Intersex
______No
______Don‘t Know
* While Ohio University Campus Care recognizes a number of genders/sexes, many insurance companies and legal entities unfortunately do not. Please be aware
that your legal name and sex you have listed with your insurance company must be used on documents pertaining to insurance, billing and correspondence. If your
preferred name and pronouns are different from these, please let us know.
Ethnicity
Race
Language
Hispanic or Latino Origin
White
Is English your primary language?
Not of Hispanic or Latino Origin
Black or African American
______Yes
Asian
If no, list your primary language:
American Indian or Alaskan Native
___________________________
______No
Native Hawaii or Other Pacific Islander
Other_______________________
Emergency Contacts
______________________________
Last Name
____________________________
First Name
__________________
Contact Number
__________________
Relationship
______________________________
Last Name
____________________________
First Name
__________________
Contact Number
___________________
Relationship
Allergies
List all medication and food allergies, include the reaction:
Medications
List all medication(s) you are currently taking, including prescription, over the counter, and herbal medication:
Vaccines
Are all your vaccinations up to date? ______Yes ______No
Attach a copy of an official immunization record if possible.
Surgical History
List ALL surgeries and dates or years (if known), including if you have had your wisdom teeth removed:
Family History
Do any family members have, or have they ever had any of the following?
Heart Attack:
______Yes
______No
If yes, who? _________________________________
Stroke:
______Yes
______No
If yes, who? _________________________________
Diabetes:
______Yes
______No
If yes, who? _________________________________
High Blood Pressure:
______Yes
______No
If yes, who? _________________________________
Blood Clot in lung or leg: ______Yes
______No
If yes, who? _________________________________
Bleeding Disorders:
______Yes
______No
If yes, what type and who? _____________________
Cancer:
______Yes
______No
If yes, what type and who? _____________________
Social History
Alcohol Intake:
______None
______Occasional
______Moderate
______ Heavy
How many drinks per day? _______________________________________
At what age did you start drinking? ________
Smoking:
______None
______Occasional
______Moderate
______ Heavy
How many cigarettes per day? ____________________________________
At what age did you start smoking? _________
Chewing Tobacco:
______None
______Occasional
______Moderate
______Heavy
How much do you chew per day? __________________________________
At what age did you start chewing? _________
Caffeine Intake:
______None
______Occasional
______Moderate
______Heavy
Exercise Level:
______None
______Occasional
______Moderate
______Heavy
Dietary Restrictions:
______Yes
______No If yes, list: _____________________________
Occupation: _______________________________
Major: _____________________________
List any illegal drugs that you use (marijuana, cocaine, heroin, bath salts, etc.):
List any prescription medications that you take that are NOT prescribed to you, such as Adderall or Xanax:
Sexual History
Have you ever been sexually active? ______Yes ______No
Number of sexual partners in your life? ____ Last 12 months? ____
What percent of time do you use condoms?______% ___N/A
Sexual Orientation/Interest: ______Interested in men
What other forms of birth control do you use? ______________
______ Interested in women
______ Interested in women and men
Hospitalizations
Have you ever been hospitalized overnight?
If yes, list when and why:
______Yes ______No
Medical History
List any current and/or past health problems, including both physical and psychiatric:
______No past medical problems
Head and Neck: ______________________________________________________________________________
Mental health: _______________________________________________________________________________
Eyes, Ears, Nose, and Throat: ____________________________________________________________________
Heart: ______________________________________________________________________________________
Digestion: ___________________________________________________________________________________
Lungs: ______________________________________________________________________________________
Bladder or Kidney: ____________________________________________________________________________
Blood: ______________________________________________________________________________________
Muscle, Joint or Bone: _________________________________________________________________________
Cancer: _____________________________________________________________________________________
Diabetes: ____________________________________________________________________________________
Seizures or Convulsions: ________________________________________________________________________
Skin: ________________________________________________________________________________________
Other: _______________________________________________________________________________________
Gynecological History
First day of Last Menstrual Period: ______________________ Age at onset of periods: ______________________
Are your periods regular? ______Yes ______No
Menstrual flow: ______Light
______Moderate
Duration of period: __________________________
______Heavy
How often do you have a period? ______________________
Authorization
I authorize and request Ohio University Campus Care, services provided by University Medical Associates, Inc. to administer all
requested and/or indicated outpatient medical and surgical services, immunizations and to perform emergency procedures, as
necessary, or to refer to other duly licensed medical personnel for necessary emergency treatment when indicated, including
transfer to external facilities.
________________________________________________
Student’s Signature
Date
____________________________________________
Parent/Guardian Signature
Date
*Only for students under the age of 18