Student Health Profile

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Student Health Profile

Personal Information

Name*

First Name

Last Name

Social Security Number*

Address*

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Country

Email*

Emergency Contact

Name*

First Name

Last Name

Phone*

Address*

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Country

General Information

Prescription medications taken regularly require a written physician's explanation of the reason for taking.

Insurance Information

Company*

Group/Policy*

Policyholder*

First Name

Last Name

S.S.#*

Previous Physicians

Name

First Name

Last Name

Specialty

Address

Address Line 1

Address Line 2

City

State

ZIP Code

Name

First Name

Last Name

Specialty

Address

Address Line 1

Address Line 2

City

State

ZIP Code

Limitations

Do you have a physical limitation or a known learning disability?*

Yes No

Please Explain*

Allergies

Are you allergic to any medication, food, or substance?*

Yes No

Will you need allergy injections during the semester?*

Yes No

Please specify each allergy.*

Medications

List medications used on a regular basis, doses, and reasons for taking.*

Will you need injections while attending Crown College?*

Yes No

Specify the type of injection*

Previous and Present Medical Problems

Hospitalizations - Please include diagnosis and dates.*

Surgeries - Please include type of operation(s) and dates.*

Injuries - Please include type, complications, any permanent disabilities and dates.*

Have you ever used any illegal, injectable, or recreational drugs?*

Yes No

List the type of drug, approximate length of usage, and when last used.*

Have you ever used alcohol on a regular basis?*

Yes No

Please list approximate length of usage and when last used.*

Medical History

Diabetes*

Diet Control Insulin Oral Medication

Parasitic Disease*

Give details for any condition.*

Out of concern for the health and safety of our student body, if a student has chronic health episodes during the semester (including but not limited to eating disorders, self-harm, fainting, loosing consciousness, seizures, etc.) that interfere with his or her education, campus life, or dorm life, the student will be asked to withdraw from the college for his or her own personal health. The student may be permitted to return to school the next semester if the health condition has been resolved.

Mental Health

Has your job or schooling ever been interrupted because of emotional problems?*

Yes No

Please explain*

Have you ever been diagnosed with an eating disorder such as anorexia or bulimia?*

Yes No

Please explain*

Have you ever been hospitalized or treated for anxiety, depression, or psychosis?*

Yes No

Please explain*

Immunizations (required prior to registration)

Will you be claiming exemption from immunizations?*

Yes No

Rubella (German Measles)

Date Received

Ruboela Measles 1st Shot

Date Recieved

Ruboela Measles 2nd Shot

Date Received

Diphtheria/Pertussis/Tetanus Injections 1.

Date Received

Diphtheria/Pertussis/Tetanus Injections 2.

Date Received

Diphtheria/Pertussis/Tetanus Injections 3.

Date Received

Diphtheria/Pertussis/Tetanus Injections 4.

Date Received

Diphtheria/Pertussis/Tetanus Injections 5.

Date Received

I, the undersigned, choose exemption from the following listed immunization(s):*

MMR (Measles) Diphtheria/Pertussis/Tetanus Injections The Tetanus Toxoid Booster

Note: Anyone exempting from the MMR (Measles) immunization will be sent home immediately if any case of measles breaks out on campus.

Reason(s) for exemption:*

Religious Exemption Physiological/Ideological Objection History of Adverse Reaction

Name*

First Name

Initial

Last Name

Signature*

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