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 ??????.

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

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.
For insurance purposes, if different from above.
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.