HEALTH HISTORY FORM. Student PID Number Date of Birth Legal Sex Preferred Pronouns Relationship Status (ie. he/him, she/her, they/their)
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1 2 Health Center Drive Athens, OH Tel: (740) Fax: (740) HEALTH HISTORY FORM Legal Name Last First Middle Initial Preferred Name Student PID Number Date of Birth Legal Sex Preferred Pronouns Relationship Status (ie. he/him, she/her, they/their) Preferred Mailing Address Preferred Contact Number OHIO What was your sex assigned at birth? Female Male Intersex Do you identify as transgender or transsexual? 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 Asian American Indian or Alaskan Native Native Hawaii or Other Pacific Islander Other If no, list your primary language: 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:
2 Vaccines Are all your vaccinations up to date? Attach a copy of an official immunization record if possible. If records are available, they can be sent to hsmw@ohio.edu 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: Stroke: Diabetes: High Blood Pressure: Blood Clot in lung or leg: Bleeding Disorders: If yes, what type and who? Cancer: If yes, what type and who? Social History Alcohol Intake: ne Heavy How many drinks per day? At what age did you start drinking? Smoking: ne Heavy How many cigarettes per day? At what age did you start smoking? Chewing Tobacco: ne Heavy How much do you chew per day? At what age did you start chewing? Caffeine Intake: ne Heavy Exercise Level: ne Heavy Dietary Restrictions: 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? 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
3 Hospitalizations Have you ever been hospitalized overnight? If yes, list when and why: Medical History List any current and/or past health problems, including both physical and psychiatric: 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? Duration of period: Menstrual flow: Light 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
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Page 1 of 5 Gastroenterologists: D.F. Jackson, III, MD William D. McLaughlin, MD Robert P. Albares, MD Jeffrey J. Crittenden, MD Samuel J. Tarwater, MD Travis J. Rutland, MD Gastroenterologists: Marc L.
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MONTEFIORE MEDICAL CENTER TRANSPLANT PROGRAM LIVING DONOR EVALUATION FORM History Questionnaire Donor s Name: Today s Date: Social Security #: Date of Birth Age Sex Address: Telephone #: (home) (work)
History Form for Exceptional Home-Based Care
Patient Name: ; Birth date: / / ; Date: / / Person filling out form: ; Relationship: Thank you for taking the time to fill out this valuable information. This allows us to provide the best care possible
2018 Union County Youth Risk Behavior Survey Results
2018 Union County Youth Risk Behavior Survey Results METHODS The Union County Youth Risk Behavior Survey (YRBS) was previously conducted in 2009,* 2010, 2012, 2014, and 2016. Information gathered from