Medical History Form

Required Vaccinations
Required Vaccinations
Recommended Vaccination
Please fully complete and submit the form below AND upload the following required medical documents for enrollment:

1) Childhood vaccination records (these must be submitted before a residential student can move into campus housing or before a commuter student can attend class)

2) COVID-19 Vaccination Card (if you have been vaccinated)

3) Health Insurance Card

4) Any other medical records you want to share with our Medical Services Department (this is optional)
Personal Information
Name *

First Name Middle Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number *

Area Code Phone Number
Social Security Number
Date of Birth *
Gender
Health Insurance Information

A copy of the student's health insurance card should be uploaded at the end of this form.
Health Insurance (Company Name)
Health Insurance (Company Address)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Name of Insurance Policy Holder
Policy Holder's Employer Name
Policy/Certificate Number
Policy Group Number
Emergency Contact Information
Name of Emergency Contact Person #1 *

First Name Last Name
Phone Number of Emergency Contact Person #1 *

Area Code Phone Number
Name of Emergency Contact Person #2

First Name Last Name
Phone Number of Emergency Contact Person #2

Area Code Phone Number
Personal Health History

The following health history is confidential, does not affect the student's admission status, and may only be shared with other health care professionals on an as needed basis to ensure the student receives required and/or requested treatment and care, as necessary.

Have you ever had or do you now have: *

	Yes	No	Year
High blood pressure
Rheumatic fever
Heart trouble
Pain or pressure in chest
Shortness of breath
Asthma
Pneumonia
Chronic cough
Head or neck radiation treatments
Tumor or cancer (specify)
Malaria
Thyroid trouble
Diabetes
Serious skin disease
Mononucleosis
Hay fever
Allergy injection therapy
Arthritis
Concussion
Frequent/severe headaches
Dizziness or fainting spells
Severe head injury
Paralysis
Disabling depression
Excessive worry or anxiety
Ulcer
Intestinal trouble
Pilonidal cyst
Frequent vomiting
Gall bladder trouble or gallstones
Jaundice or hepatitis
Rectal Disease
Severe or recurrent abdominal pain
Hernia
Easily fatigued
Anemia or Sickle Cell Anemia
Eye trouble other than glasses/contact lenses
Bone or joint deformity
Knee problems
Recurrent back pain
Neck injury
Back injury
Broken bone (specify)
Kidney infection
Bladder infection
Kidney stones
Protein or blood in urine
Hearing loss
Sinusitis
Severe menstrual cramps
Irregular periods
Sexually transmitted disease
Blood transfusion
Alcohol use
Drug use
Anorexia/bulimia
Smoke 1+ pack cigarettes weekly
Regular exercise
Other (specify)

Have you ever experienced adverse reactions (hypersensitivities, allergies, upset stomach, rash, hives, etc.) to any of the following? *

	Yes	No	Explanation
Penicillin
Sulfa
Other antibiotics (specify)
Aspirin
Codeine/other pain relievers
Other drugs, meds (specify)
Insect bites
Food allergies (specify)

Please indicate with an "X" if Yes or No for each item below. If yes, please provide an explanation. *

	Yes	No	Explanation
Do you have any conditions or disabilities that limit your physical activities?
Have you ever been a patient in any type of hospital?
Has your academic career been interrupted due to physical or mental conditions?
Is there loss or seriously impaired function of any paired organs?
Other than for a routine check up, have you seen a physician for any other conditions?
Have you ever had any serious illness or injuries other than those already noted?

Please list any drugs, medicines, birth control pills, vitamins/minerals (prescription and non-prescription) you use and indicate how often you use them.

	Medication Name	Use	Dosage/Frequency
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5

CONTINUED: Please list any additional drugs, medicines, birth control pills, vitamins/minerals (prescription and non-prescription) you use and indicate how often you use them.
Family Health History

Has anyone in your immediate family had any of the following? *

	Yes	No	Relationship
High blood pressure
Stroke
Heart attack before age 55
Blood clotting disorder
Cholesterol or blood fat disorder
Diabetes
Cancer (specify)
Glaucoma
Alcoholic/drug problems
Psychiatric illness
Suicide
Other (specify)

Document Uploads

Do not forget to upload your documents before submitting this form.
Please upload the following documents here before submitting this form: 1) Childhood vaccination records (these must be submitted before a residential student can move into campus housing or before a commuter student can attend classes). 2) COVID-19 Vaccination Card (if you have been vaccinated) 3) Health Insurance Card 4) Any other medical records you want to share with our Medical Services Department

Browse Files

Cancel of
Acknowledgement
Please read the statements below:

A) I have personally supplied and reviewed the information on this form and attest it is true and complete, to the best of my knowledge. I understand the information is strictly confidential and will not be released to anyone without my written consent, or as otherwise permitted by law. If I should be ill, injured, or otherwise unable to sign the appropriate forms, I hereby give my permission to the institution to release information from this form to a physician, hospital, or medical professional involved in providing me with emergency treatment and/or medical care.

B) I hereby authorize any medical treatment for myself that may be advised or recommended by the Director of Medical Services.

C) I am aware I may be charged for some health services provided by the University and I may be billed through the University Business Office, if the account is not paid at the time of the visit. I accept personal responsibility for settling the account with the University Business Office and for payment of incurred charges. I am responsible for filing outpatient charges with my insurance. I also acknowledge my responsibility to Mars Hill University is unaffected by the existence of insurance coverage.

CONTINUE BELOW TO SIGN THE ACKNOWLEDGEMENT
Electronically sign in the box below to indicate your acknowledgement of the statements on the previous screen. *

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Personal Information

Health Insurance Information

Emergency Contact Information

Personal Health History

Family Health History

Document Uploads

Acknowledgement