BRIEF PERSONAL AND FAMILY HEALTH HISTORY

Last Name:______First Name:______MI: __ Preferred Name: ______

CWU Student ID:______DOB______Sex: □ Male□ Female□ Other

Please mark (x) in the appropriate space if you or any immediate family members have had any of the following:

# / You / Family / # / You / Family
1 / ADD/ADHD/Learning Disability / 15 / Hepatitis
2 / Alcohol/Drug Dependency / 16 / High Blood Pressure
3 / Anemia or Blood Conditions / 17 / Immunocompromising Cond./HIV
4 / Arthritis / 18 / Kidney Disease
5 / Asthma/Lung Disease/Pneumonia / 19 / Migraines/Severe Headaches
6 / Bulimia/Eating Disorder / 20 / Mobility Limitations
7 / Cancer / 21 / Mononucleosis
8 / Depression/Anxiety/Psychological Disorder / 22 / Neurologic Conditions
9 / Diabetes / 23 / Seizure Disorder/Epilepsy
10 / Gastrointestinal Disorder / 24 / Spinal Injury
11 / Gynecologic Problems / 25 / Stroke
12 / Head Injury/Concussion/ Loss of Consc. / 26 / Thyroid Disorder
13 / Hearing Loss / 27 / Tuberculosis
14 / Heart Disease / 28 / Vision Impairment

**If NONEof the above apply, Initial Here: ______

Explain any (x) positive Answers: (e.g. Mother/Father history of Diabetes.) Attach extra sheets if necessary. ______

  1. Do you have any allergies (medication, food, environmental)? □ Yes □No

If YES, explain______

  1. What Medications are you currently taking (over-the-counter and prescription)? ______
  2. Do you need specific medical assistance (i.e. allergy injections, disability accommodations)?□ Yes □ No

______

  1. Do you want us to contact you for an appointment following move-in? □ Yes □No
  1. If YES, what is the best phone number to contact you at?______

NOTICE OF PRIVACY PRACTICE:Information discussed while participating in the patient centered medical home servicewill be confidential and only released when you specifically grant permission or when required by law. In the event that the psychologist determines that you may be a harm to yourself or someone else or if you confide that someone under 18 years of age, a dependent adult, or elderly person is the victim of neglect, or physical abuse, or sexual abuse, the psychologist in the program is required by law to report to the appropriate authorities, as necessary, to prevent further harm. Information disclosed will likely be discussed with other clinical staff, such as your medical provider. Be aware that some careers may require you to release your medical and/or psychological record information in order to be eligible for employment. If this is a concern for you please discuss this with the psychologist in the program.

CONSENT FOR TREATMENT: I consent to treatment, health care operations and responsibility for billed procedures at the CWU: Student Medical & Counseling Clinic.

SIGNATURE:______DATE:______

CWU Student Medical Counseling Clinic

400 East University Way • Ellensburg WA 98926-7585

Medical Office: 509-963-1881 • Counseling Office: 509-963-1391 • Fax: 509-963-1886

EEO/AA/Title IX Institution • For accommodation e-mail:

S:\Health_Center\SMaCC Shared\Health History-2016 (002).doc