Health History Form

Ottawa University Arizona requires that all students complete the OUAZ Health History Form prior to starting courses. If you have questions, please contact us at 855-546-1342.

Include your first name, middle initial and last name.
Do you participate in athletics at OUAZ?:

Do you currently take medications?:

(including birth control and any psychotropic medications for anxiety, ADHD, depression, etc.)
Are you allergic to any medications?:

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

Injury History :

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.
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For insurance purposes, if different from above.
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Have you had a medical illness or injury since your last check up or sports physical?:

Do you have an ongoing or chronic illness?:

Have you ever been hospitalized overnight?:

Have you ever had surgery?:

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

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

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

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

Have you ever passed out during or after exercise?:

Have you ever been dizzy during or after exercise?:

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

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

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

Have you had high blood pressure or high cholestrol?:

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

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

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

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

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

Have you ever had a head injury or concussion?:

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

Have you ever had a seizure?:

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

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

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

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

Do you have asthma?:

Do you use an inhaler before exercise?:

Do you have seasonal allergies requiring medication?:

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

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

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

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

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

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

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

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

Females only - Have you begun menstruation?:

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

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

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

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

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

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

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

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