Hillsdale College - Health Form

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INSTRUCTIONS: Complete all items of this health form. Where questions are not applicable, use symbol "N/A."

IMPORTANT: This form must be completed, returned to the College, and determined complete by Health Services before you can register with the Admissions Office. Information supplied will be used as an aid in necessary care while you are a student.

If this student will not be 18 years old by the first day of classes, please contact the admissions department and fill out a hard copy of this form, with parent signature.

Note: Items marked with an asterisk “*” are required.

I. General Information:

Status:
*
First Name:
*
Last Name
*
Street Address:
*
City:
*
State:
*
Zip:
*
Telephone:
*
E-mail:
*
Sex:
*
Date of Birth:
Month: * Day: * Year: *
Country of Birth:
*
Religion:
Marital Status:
*

Parent or Guardian

Name:
*
Address:
*
City:
*
State:
*
Zip:
*
Phone:
*

Family Physician:

Name:
Address:
City:
State:
Zip:
Phone:

II. Family History:

Father:

General Health:
*
If deceased, give cause:

Mother:

General Health:
*
If deceased, give cause:

Brothers:

No. Living:
*
Health:
If any deceased, give cause:

Sisters:

No. Living:
*
Health:
If any deceased, give cause:

Indicate which of your (blood) relatives have had any of the following diseases:

Arthritis
*
Cancer:
*
Diabetes:
*
Epilepsy:
*
Heart Disease:
*
Kidney Disease:
*
Stroke:
*
Tuberculosis:
*
Mental Health Concerns:
*
Substance Abuse Issues:
*
Any additional comments on Family History:

III. Personal History:

Please indicate immunizations you have received by providing us with dates you received them:

¹Tetanus-Diptheria-Pertussis (TDaP)–within last 10 years:
*
¹Hepatitis B–three doses required:
* * *
¹Meningococcal–initial:
*
¹Meningococcal–booster:
*(required if 5 years after initial)
¹Measels, Mumps, Rubella (MMR)–two doses required:
* *
¹Polio–Four doses required:
* * * *
¹Tuberculin (TB) skin test or negative chest X-Ray in the last 3 years:
*
¹Varicella (Chicken Pox)–history:
*
OR
¹Varicella (Chicken Pox)–two doses of vaccine:
* *

¹ These are required vaccinations. A student can request exemption from immunizations by completing the Immunization Waiver form and sending or faxing it to the Hillsdale College Health and Wellness Center.

Note: Please send/email/fax an official immunization record to the Health and Wellness Center so there can be a complete student health record.
Contact Info: 183 Hillsdale St., Hillsdale, MI 49242
Email: cdrews@hillsdale.edu
Phone: (517) 607-4368
Fax: (517) 607-2222

Height:
*
Weight:
*
General Health During Childhood:
*
Check each illness that you have had by indicating the year or "N/A":
- ADHD:
  *
- Alcohol/Other Drugs Issue:
  *
- Allergy Injections:
  *
- Anxiety:
  *
- Asthma:
  *
- Bipolar Disorder:
  *
- Bone/Joint Problems:
  *
- Cancer:
  *
- Chickenpox:
  *
- Chronic Colds:
  *
- Depression:
  *
- Diabetes:
  *
- Eating Disorder/Low Weight:
  *
- Epilepsy/Seizures:
  *
- Fainting Spells/“Blacking Out”:
  *
- Headaches:
  *
- Head Injury:
  *
- Hearing Problems:
  *
- Heart Problems:
  *
- Hepatitis/Liver Disease:
  *
- High Blood Pressure:
  *
- Kidney/Urinary Problems:
  *
- Measles:
  *
- Menstrual difficulties:
  *
- Mumps:
  *
- Mononucleosis:
  *
- Neurological Problem or Seizures:
  *
- Rubella:
  *
- Scarlett Fever:
  *
- Sinus Issues:
  *
- Skin Problem:
  *
- Sleep Disorder:
  *
- Strep Throat:
  *
- Thyroid Disorder
  *
- Vision (other than corrective lenses)
  *
- Comments on any above listed conditions:
- Other/Not Listed
Have you ever been hospitalized or had surgery? If yes, for what purpose and which dates?
Please list any other injuries:
Do you smoke cigarettes?
*
Do you wear glasses or contact lenses?
*
Date of last eye examination:
*
Date of last dental examination:
*
Do you take any medication regularly?
*
If yes, for what?
Are you allergic to any medications, food, etc?
*
If yes, explain:
Is there anything in your physical or mental or emotional condition to limit your college activities?
*
If yes, please describe:

* We hereby authorize immunizations and treatments that are deemed necessary while the above-named student is attending Hillsdale College. We also consent to emergency treatment by a licensed physician at an approved medical facility with use of such anesthesia and medical or surgical procedures as may be deemed necessary for care. We understand that in case of a serious illness or accident we will be notified.

Name:
*
Address:
*
City:
*
State:
*
Zip:
*
Phone:
*
Date:
*
Witness Name:
*

Insurance Information:

Students are required to show proof on insurance coverage at the time of registration. Students should be aware of the types of benefits their insurance affords and should carry a card with the policy number and information.

Primary Insurance Information

Insured's Name (Parent):
*
Insured's Address:
*
City:
*
State:
*
Zip:
*
Phone:
*
Insured's Date of Birth (MM/DD/YYYY):
*
Insurance Company Name:
*
Address:
*
Group Name:
*
Contract Number:
*

Secondary Insurance Information

Insured's Name (Parent):
Insured's Address:
City:
State:
Zip:
Phone:
Insurance Company Name:
Address:
Group Name:
Contract Number:

Parent's Employment Information

Place of Business or Employment (Parent):
Place of Business or Employment Address:
City:
State:
Zip:

33 East College St. Hillsdale, MI 49242

• Tel: +1 517 437-7341 • Fax: +1 517 437-3923