Confidential Health Report

Confidential Health Report

To be completed by students residing in campus housing. Please print clearly, sign, date and return completed form to:

Health Services Office

Coulter Library, Room 103

OnondagaCommunity College

4585 West Seneca Turnpike

Syracuse, New York13215-4585

Name: ______Date of Birth:______

Student ID#:______Residence Hall Building & Suite:______

HomeAddress:______

StreetApt. #CityStateZip Code

Home Phone: ______Cell Phone:______Email Address:______

Area CodeNumber Area CodeNumber

How would you describe your overall health status? ______

______

Medical History Height ______Weight ______Age ______

Have you had or do you now have the following diagnosed problems?

(Please use the line below each item to provide additional/specific information if you have checked yes)

High blood pressure[] yes[] no

______

Diabetes[] yes[] noInsulin ____ Diet controlled _____ Medication _____

______

Thyroid disorder[] yes[] no

______

Allergies[] yes[] no Bee Sting ___ Environmental _____ Medication _____

______

Seizures[] yes[] no

______

Heart - congenital heart defects, heart surgery, heart murmur, heart disease[] yes [] no

______

Respiratory/ Lung problems – Asthma, pneumonia, bronchitis or other [] yes [] no

Stomach or Intestinal problems – GERD, Ulcer, Crohn’s, or other[] yes [] no

Cancer or blood disorder: hemophilia, leukemia, melanoma or other [] yes [] no

______

Mental Health Issue: eating disorder, mood disorder, anxiety, panic attacks or other [] yes [] no

______

Addictions/Alcoholism [] yes [] no

______

Are you currently under medical care for any problems listed? [] yes [] no

If yes, please list prescribed medications or treatments:

______

Have you had surgery in the past year? [] yes [] no

If yes, please explain:

______

Have you had a serious injury in the past year requiring medical attention? [] yes [] no

If yes, please explain:

______

Do you have a physical disability? [] yes [] no

If yes, please check any/all accommodative devices that you use:

Artificial Limb_____Brace_____ Cane_____

Crutches_____ Hearing Aid_____ Wheelchair_____

If you use accommodative device(s) not included above, please list:

______

Do you smoke? [] yes [] no

If yes, please estimate the frequency and quantity of your tobacco use: ______

Please note: Smoking is restricted to areas 50 feet from buildings. There is no smoking in or near any building on campus, including the residence halls.

Do you drink alcohol? [] yes [] no

If yes, please indicate the type of alcohol you are most likely to consume:

Beer_____Liquor_____Mixed Drinks______Wine____

If yes, please also estimate the frequency and quantity of your alcohol consumption: ______

Please note: OnondagaCommunity College, including the residence halls, is an alcohol and drug free zone.

Please list any other information the Health Services Office should be aware of.

______

Do you have a doctor? [] yes [] no

Physician’s Name: ______Phone: ______

Area Code Number

I certify that the information provided on this form is complete and accurate to the best of my knowledge.

Student’s Signature ______Date ______

Prepared: 9/23/08