Medical History (Confidential) Return Completed Form To: MSSU Health Center

Medical History (confidential) Return completed form to: Willcoxon Health Center

Completion of this form is required prior to 3950 E Newman Rd

receiving non-emergency care. Joplin, Mo 64801

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Name:______Sex: M F Age: _____ Date of Birth:____/____/__

Last First Middle mm/dd/yy

Local Address:______Telephone: ______

Street City State Zip

Marital Status: Single/Married/Widowed/Divorced Race:______

Name of Nearest Relative:______Relationship:______

Address of Nearest Relative:______Telephone:______

Street City State Zip

Family or Primary Physician: ______Address:______

Phone numbers where parents can be reached in an emergency:______

I will enter MSSU:______Classification: Fr/Soph/Jr/Sr/Employee/Other

Semester/Year

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Have you ever had or do you have now, a problem with:

____Alcohol____Drug Abuse____Joint Disease/Injury____Sickle Cell Trait/Anemia

____Anemia____Ear Trouble/Hearing Loss____Measles, Red____Sinus Trouble

____Arthritis____Eating Disorder____Migraine Headaches____Skin Problems (Chronic)

____Asthma____Eye Disease/Problems____Mononucleosis, Infectious____Sleep Problems

____Back Problems____Gallbladder Trouble____Mumps____Smoking (How long?)

____Cancer____Hay Fever (Recurrent)____Paralysis____Suicide Attempt

____Chicken Pox____Head Injury____Pneumonia____Surgery

____Colitis____Headache (Recurrent)____Polio____Thyroid Disease

____Convulsions/Seizures____Heart Disease/Problem____Psychological Counseling____Tuberculosis

____Cough (Chronic)____Hepatitis/Jaundice____Rheumatic Fever____Urinary Tract Infection

____Depression____Hernia/Rupture____Rubella (3 Day Measles)____Other

____Diabetes____High Blood Pressure____Scarlet Fever

____Disability/Handicapped____Intestinal/Stomach Trouble____Sexually Transmitted Disease (STD)

If none of the above apply, check here:______

Describe answers above with dates:______

______

List Drug Allergies: Date of last Physical exam: List Current Medications:

__________________

______Height:______

______Weight:______

______While at MSSU will you need______Allergy Shots?______

If none known, check here:_____(If “yes” bring written instructions from your physician)

Please attach a copy of your Immunization Record!

Proof of (2) doses of MMR is REQUIRED! Date(s) of both (If already rec’d) ______

______

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STUDENTS LIVING IN RESIDENCE HALLS ARE REQUIRED, BY LAW, TO HAVE A MENINGITIS VACCINE,

OR SIGN A WAIVER REFUSING IT!

Meningitis is an infection that is rapidly progressive and may be mistaken for Influenza. It can progress from flu-like symptoms

to death within 24 to 48 hours. College freshmen living in residence halls are at a 6-fold higher risk for meningitis compared

with other college students. The Meningitis vaccine is available at the Willcoxon Health Center at cost.

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PARENTS OF STUDENTS UNDER AGE 18: I hereby grant permission to the medical staff of the MSSU Health Center to carry

out necessary medical treatment of the above patient. ______

Signature of Parent/Guardian Date

BILLING POLICY: While office visits are free, some services have fees. Students may pay charges at the time of service,

or can be billed by Student Accounts, payable within 30 days.FACULTY/STAFF CHARGES ARE DUE AT THE TIME OF SERVICE!

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Name (print)

______

LAST FIRST MIDDLE STUDENT NUMBER DATE

Please complete reverse side.

______

Family History

Relation AgeState of HealthAge at DeathCause of Death______

Father______

Mother______

Sisters______

Brothers______

Has any relative (father, mother, sister, brother, or grandparent) suffered from the following:

Yes No Relationship

______

Arthritis______

Asthma______

Cancer (what type?)______

Diabetes______

Epilepsy/Seizures______

Heart Attack (before age 50)______

High Blood Fat Levels______

High Blood Pressure______

Kidney Disease______

Mental Disease/Disorder______

Migraine Headaches______

Sickle Cell Trait/Disease______

Stomach/Colon Problems______

Thyroid Disease______

Tuberculosis______

Other______

Any other information which could be helpful in your care at MSSUHealthCenter?

______

______

______

______

For females only:

Age at first menstrual period: ______Menstrual irregularities? Yes / No How many pregnancies? ______

______

I hereby certify that the above history is complete to the best of my knowledge.

______

Name Date Social Security Number

Medical history form 02/11