Medical History
Applicant Instructions	Anticipated Enrollment:    Fall    Spring    Summer     Year      
Last Name
     	First Name
     	Middle or Maiden
     	Preferred Name
     	
Current Address
     	City/State/Zip
     	Birth Date
     	
Last 4 digits of Social Security #
     	College Classification
 Freshman    Sophomore    Junior    Senior	Marital Status
 Married    Single    Divorced	
Do you have any history of the following illnesses?
	 Asthma	 Epilepsy	 Poliomyelitis	 Thyroid	 Chickenpox	 Malaria
	 Rheumatic Fever	 Tuberculosis	 Diabetes	 Measles	 Scarlet Fever	 Typhoid Fever
	 Diptheria	 Mumps	 Smallpox	 Whooping Cough	
Do you have any allergies?
	Food?	 Yes    No	Please List:	     		
	Medicine?	 Yes    No	Please List:	     	
	Other?	 Yes    No	Please List:	     	
Have you ever been treated for:     Emotional instability    Psychological problems    Trauma    Mental illness
List any other illnesses:       	
List any major health problems:       	
List major surgeries/procedures and give the approximate dates:       	
     	
Do you have a physical handicap?    Yes    No        If so, please explain:       	
Do you consider your general health good?    Yes    No        If not, please give details       	
     	
Are you taking any prescription or over-the-counter medications regularly?   Yes    No
	If so, please list names, dosages, and frequency:       		
Family Health Information
	Name	Age	Occupation	Age at death	Cause of death	
Father	     	     	     	     	     	
Mother	     	     	     	     	     	
Siblings	     		     	     		     	     		
	     	     	     	     	     	
	     	     	     	     	     	

Required Immunizations:	All students under 30 years of age taking on campus classes are required to have the following immunizations.
				Official shot records are required.

Meningitis (within last 5 years)	Completed    Yes    No	Date of last injection:       	
Mumps/Measles/Rubella	Completed    Yes    No	Date of first injection:       		Date of last injection:       	
	(2 Dates Required: MMR Booster required for all students.)	
Polio (if under age 19)	Completed    Yes    No	Date of last injection:       	
	(Poliomyelitis: Minimum of three doses (oral) with at least one dose since 4th birthday.) 
TB Skin Test (within last year)	Completed    Yes    No	Date of test:	     		Results: