Health History Form | Ottawa University

Full Name:

Include your first name, middle initial and last name.

Nickname:

DOB:

OUAZ ID:

Email:

Do you participate in athletics at OUAZ?:

Yes
No

If yes, which team(s)?:

Do you currently take medications?:

Yes
No

List the medications you take:

(including birth control and any psychotropic medications for anxiety, ADHD, depression, etc.)

Are you allergic to any medications?:

Yes
No

If yes, list medications you have an allergy to:

Disease/Illness History - Please check the boxes if you have now or ever had:

Abnormal Heartbeat
Allergies
Asthma
Birth Deformities
Bone/Joint Weakness
Chest Pain
Chicken Pox
Convulsions
Depression
Diabetes
Diphtheria
Eating Disorder
Fainting Spells
Head Injury
Headaches
Hearing Problems
Heart Murmur
Heat Exhaustion/ Stroke
Hepatitis
Hernia
High Blood Pressure
High/Low Blood Sugar
Hives
Kidney Troubles
Malaria
Measles
Mental Health Issues
Mononucleosis
Mumps
Pneumonia
PTSD (Post Traumatic Stress Disorder)
Rheumatic Fever
Scarlet Fever
Seizures/Epilepsy
Sickle Cell
Skin Condition
Small Pox
Tuberculosis
Unusual Shortness of Breath
Vision Difficulty
Whooping Cough
None to Date

Explain any above marked items:

Injury History :

Abdomen/Pelvis
Ankle
Arm
Back
Calf
Chest/Breast
Elbow
Foot
Hand
Head
Heart
Hip
Knee
Neck
Shoulder
Thigh
Wrist
None to Date

Please check the boxes if you have now or ever had an injury (sprain, strain, fracture or dislocation of a muscle, tendon, bone or joint) or illness involving the above.

Explain any above marked items:

Family Physician:

Phone Number:

( ) -

Fax Number:

Address:

City/State/Zip:

Primary Care Physician:

For insurance purposes, if different from above.

U.S. phone number:

( ) -

Fax Number:

Address:

City/State/:

Proof of Immunization - please submit a copy of your updated immunization records:

Insurance Policy Holder's Name:

Phone Number:

( ) -

Relationship of Policy Holder to you:

Have you had a medical illness or injury since your last check up or sports physical?:

Yes
No

Do you have an ongoing or chronic illness?:

Yes
No

Have you ever been hospitalized overnight?:

Yes
No

Have you ever had surgery?:

Yes
No

Are you currently taking any prescription or non-prescription (over-the-counter) medications or pills or using an inhaler?:

Yes
No

Have you ever taken any supplements or vitamins to help you gain or lose weightor improve your performance?:

Yes
No

Do you have any allergies (for example, to pollen, medicine, food, or stinging insects?:

Yes
No

Have you ever had a rash or hives develop during or after exercise?:

Yes
No

Have you ever passed out during or after exercise?:

Yes
No

Have you ever been dizzy during or after exercise?:

Yes
No

Have you ever had chest pain during or after exercise?:

Yes
No

Do you get tired more quickly than your friends do during exercise?:

Yes
No

Have you ever had racing of your heart or skipped heartbeats?:

Yes
No

Have you had high blood pressure or high cholestrol?:

Yes
No

Have you ever been told you have a heart murmur?:

Yes
No

Has any family member or relative died or heart problems or of sudden death before age 50?:

Yes
No

Have you had a severe viral infection (for example, myocarditis or mononucleosis) within the last month?:

Yes
No

Has a physician ever denied or restricted your participation in sports for any heart problems?:

Yes
No

Do you have any current skin problems (for example, itching, rashes, acne, warts, fungus, or blisters)?:

Yes
No

Have you ever had a head injury or concussion?:

Yes
No

If yes, when and how many?:

Have you ever been knocked out, become unconscious, or lost your memory?:

Yes
No

Have you ever had a seizure?:

Yes
No

Have you ever had numbness or tingling in your arms, hands, legs, or feet?:

Yes
No

Have you ever had a stinger, burner, or pinched nerve?:

Yes
No

Have you ever become ill from exercising in the heat?:

Yes
No

Do you cough, wheeze, or have trouble breathing during or after activity?:

Yes
No

Do you have asthma?:

Yes
No

Do you use an inhaler before exercise?:

Yes
No

Do you have seasonal allergies requiring medication?:

Yes
No

Do you use any special protective or corrective equipment or devices that aren't usually used for our sport or position?:

Yes
No

Have you had any problems with your eyes or vision?:

Yes
No

Do you wear glasses, contacts, or protective eyewear?:

Yes
No

Do you want to weigh more or less than you do now?:

Yes
No

Has a doctor told you or a family member that you are at risk for blood disorders (for example, sickle cell, hemophilia,etc)?:

Yes
No

Were you born without or are missing a kidney, testicle, or any other organs?:

Yes
No

Do you feel that you have fatigue or increased shortness of breath with activity?:

Yes
No

Do you have any concerns that you would like to discuss with the doctor or nurse?:

Yes
No

Females only - Have you begun menstruation?:

Yes
No

If yes, approximately when was your first period?:

If yes, have you ever experienced any problems (i.e. irregularity, pain, etc.)?:

Yes
No

Identify YES responses (by number) and explain:

Have you ever received a mental health evaluation on treatment?:

Yes
No

If yes, would you like for a staff member in Counseling Services to follow up with you?:

Yes
No

Have you ever received academic support for any learning issue(s)?:

Yes
No

If so, will you be requesting accommodations to be academically successful at Ottawa University Arizona?:

Yes
No

If yes, please describe the type of accommodation that you will require and the diagnosis that prompted your request for accommodations:

Name of Current Counseling or Psychiatric Provider:

Address:

City/State/Zip:

Telephone Number:

In Case of Emergency - I hearby authorize Ottawa University Arizona to contact the following provider if I am experiencing a Mental Health Crisis.:

I consent to OUAZ to release to/receive from the following provider diagnostic information and treatment information for the purpose of stabilization of my mental health.:

List provider name.

Student Signature:

Date:

Signature of Parent, or Guardian, if student is under age of 18:

Date:

Disclosure - I hereby allow OUAZ Health Services Providers to disclose the following health information:

Appointment times and dates

Tests that have been received

Test results

Other health information

To the following people because they are involved with my health care:

Dean/Assistant Dean of Student Affairs, Ottawa University Arizona, Surprise, AZ

Counselor, Ottawa University Arizona, Surprise, AZ

Parent(s)

Spouse

Friend

Other

Please specify the name and phone number of those checked above.

Parent Name:

Phone number:

( ) -

Spouse Name:

Phone number:

( ) -

Friend Name:

Phone number:

( ) -

Other name/Relationship:

Phone number:

( ) -

Student Signature:

Date:

Signature of Parent, Guardian, if student is under the age of 18:

Date: