UNIVERSITY OF SCIENCE AND ARTS OF OKLAHOMA

STUDENT MEDICAL HISTORY
INTERNATIONAL STUDENTS

 

NAME_____________________ AGE___ SEX ___ DATE OF BIRTH_________

 

The following medical history will alert the Health Center of any diseases or problems needing follow-up care and will serve as a valuable reference in the event of illness or injury.  The information on this form is confidential and is retained in your file for use by USAO Health Services only.  Information contained on this form may be released only upon your written consent.

 

 1.  Have you ever had or have you now any serious medical illness(es)? YES___ NO___

If yes, please list illness(es) and age of occurrence______________________________________________________________________________________________

 2.  Have you ever been hospitalized?  YES____ NO____

If yes, please list reason and dates of hospitalization____________________________________________________________________________________________

3.   Have you ever had any surgeries?  YES____ NO____

If yes, please list reason and dates of surgeries____________________________________________________________________

4.   Are you currently taking any medications regularly?  YES____ NO____

If yes, please list medication, dosage, and frequency (Times per day, date you started taking medication) ______________________________________________________________________________________________________

5.   Are you allergic (hives/whelps) or sensitive (nausea/vomiting) to any medications or foods? YES____ NO____

      If yes, please list medications and foods__________________________________________________________________________________________________

 

 

 

 

THIS SECTION IS TO BE COMPLETED BY A PHYSICIAN

IMMUNIZATION REGISTER

Immunization	1ST	2ND	3RD	Booster	Other Immunizations/Tests	Date
Tetanus Booster or Tetanus Diphtheria					Tuberculin
Measles, Mumps, Rubella					Hepatitis B or C
Mumps, Rubella					Serum Immune Globulin
Polio (oral)
Typhoid (Subsequent Immunization Dates)					Other:

PHYSICIAN’S SIGNATURE______________________________

  DATE ______________________

===============================================

MEASURMENTS AND/OR OTHER FINDINGS

HEIGHT_________ WEIGHT_________ HAIR COLOR___________
EYE COLOR_________BLOOD TYPE AND RH FACTOR________________

 

FAMILY HISTORY

RELATION	AGE	STATE OF HEALTH	IF DECEASED, CAUSE	AGE AT DEATH
Father
Mother
Spouse
Brother (s) and Sister (s)
Children

 

 

HAS ANY BLOOD RELATIVE (PARENT, BROTHER, SISTER, OTHER) OR SPOUSE EVER HAD:

YES	NO	(CHECK EACH ITEM)	RELATIONSHIP
		Tuberculosis
		Syphilis
		Diabetes
		Cancer
		Kidney Trouble
		Heart Trouble
		Stomach Trouble
		Arthritis
		Asthma/Hay Fever/Hives
		Seizures
		Committed Suicide
		Chemical Dependency

HAVE YOU EVER HAD OR HAVE YOU NOW (Please Check):

	Measles (Hard) (Rubeola)		Hay Fever
	German Measles (3-day) Rubella		Tumor, Growth, Cyst, or Cancer
	German Measles (3-day) Rubella		Appendicitis
	Swollen or painful joints		Hemorrhoids or Rectal Disease
	Scarlet Fever		Frequent or Painful Urination
	Rheumatic Fever		Kidney Stones or Blood in Urine
	Mumps		Sugar or Albumin in Urine
	Whooping Cough		Boils
	Frequent or Severe Headaches		Venereal Disease
	Dizziness or Fainting Spells		Recent Gain or Loss of Weight
	Eye Trouble		Arthritis or Rheumatism
	“Color Blindness”		Bone, Joint, or other Deformity
	Ear, Nose or Throat Trouble		Loss of Arm, Leg, Finger, or Toe
	Severe Tooth or Gum Trouble		Painful or “Trick” Shoulder
	Sinusitis		Foot Trouble
	Diabetes		Blood Clots
	Thyroid Disease		Paralysis (including Infantile)
	Tuberculosis		Epilepsy or Seizures
	Shortness of Breath		Frequent Trouble Sleeping
	Pain or Pressure in Chest		Depression or Excessive Worry
	Chronic Cough		Loss of Memory or Amnesia
	Heart Problems		Skin Disease
	Palpitation or Pounding Heart		Head Injuries
	High or low Blood Pressure		Broken Bones
	Leg Cramps		Infectious Mononucleosis
	Frequent Indigestion		Immune Deficiency
	Stomach or Intestinal Trouble		Other______________________________________
	Gall Bladder Trouble or Gallstones