UAB Student Health and Wellness
Health History Form
Learning Resource Center
1714 9
th
Avenue South, 3
rd
Floor
Birmingham, Alabama 35294-1270
(205) 934-3580
Please save this form and upload it to Certifiedprofile.com.
Entering Semester: ☐ Fall ☐ Spring ☐ Summer Year_______ UAB Student No. __B______________
General Information
Full Name: _____ Gender: ☐ Male ☐ Female
Last First MI ☐ Transgendered ☐ Transitional
Date of Birth: Month: Day: Year: ______________
School: Program or Major Code: ___________________________________
CAS, Med, Dent, SHP, Nurs. etc. Education, History, Physics, Biology, etc.
Current Email address: __ ___________ Blazer ID: _ _ ___________________
Are you an International Student or Scholar? ☐ Yes ☐No If Yes, which country? ____________________________
Telephone number: _________________ __________ Height: __ ____ Weight:__________
Home Cell
Local Address: _ ____________________________________________________________________________
Permanent Address _________________ ____________________________________________________________
Primary emergency contact: Telephone number: Relationship: ___ ____
Secondary emergency contact: ______ _____Telephone number: Relationship: __ ____
Personal Health History
Medical Conditions
Please list any surgeries, asthma, diabetes, ADHD, injuries, hospitalizations, etc.
Name
Description
Year
Medications
Please list prescription, non-prescription, vitamins, birth control, etc.
Name
Description
Dosage
Food/Medicine Allergies
Please list penicillin, codeine, insect bites, antibiotics, specific food or chemical, etc.
Name
Description
Reaction
Have ever had or now have: (please check at right of each item and if yes, indicate year of first occurrence)
Yes
No
Symptom
Year
Yes
No
Symptom
Year
High Blood Pressure
Mononucleosis
Rheumatic fever
Hay fever
Heart trouble
Head/neck radiation
Pain/pressure in chest
Arthritis
Shortness of breath
Concussion
Asthma
Frequent/severe headache
Pneumonia
Dizziness/fainting spells
Chronic cough
Severe head injury
Tuberculosis
Paralysis
Tumor/cancer (specify)
Epilepsy/seizures
Malaria
Blood transfusion
Thyroid trouble
Protein in blood or urine
Serious skin disease
Ulcer (duodenal/stomach)
Hearing loss
Intestinal trouble
Sexually transmitted disease
Pilonidal cyst
Severe menstrual cramps
Allergy injection therapy
Irregular periods
Back injury
Frequent vomiting
Broken bones
Gall bladder or gallstones
Kidney infection
Jaundice or Hepatitis
Bladder infection
Rectal disease
Kidney stone
Severe/recurrent abdominal pain
Mental Health History
Sinusitis
Sleep problems
Hernia
Self-injurious Behavior
Chicken pox
Depression/bipolar
Anemia/Sickle Cell Anemia
Anxiety/panic
Eye trouble besides glasses
LD/ADD/ADHD
Bone, joint, other deformity
Eating Disorder
Shoulder dislocation
Obsessive compulsive
Knee problems
Self-induced vomiting
Recurrent back pain
Substance Use History
Neck injury
Alcohol/drug problem
Diabetes
Smoke 1+ pack cigs/week
Family & Personal Health History (to be completed by the student)
Has any person, related by blood, had any of the following?
Yes
No
Relationship
Yes
No
Relationship
High Blood Pressure
Cholesterol or blood fat disorder
Stroke
Blood clotting disorder
Cancer
Psychiatric
Heart attack before age 55
Suicide
Diabetes
Alcohol/drug problems
Glaucoma
