Medical History Form Student Medical History Name:*Date of Birth (00/00/0000)Sex Assigned at Birth: Male Female Gender Identity: Man Woman Transgender Non-Binary Other Medical ConditionsHave you ever had or have you now: Asthma Chronic Cough Shortness of breath Dizziness/ fainting Migraine headaches Hay fever/sinusitis Severe Head Injury Concussion Hearing Loss Vision Problems Back Injury/Back Pain Neck Injury Shoulder Disloction Broken Bones Bone deformity Paralysis Knee problems Arthritis Alcohol/drug problem Eating Disorder Disabling Depression Social Anxiety General Anxiety / panic Self-induced vomiting Self-injurious behavior Obsessive compulsive LD/ADD/ADHD Smoking/Tobacco use Sleep problems Frequent vomiting Gallbladder or gallstones Jaundice Hepatitis Rectal disease Severe/recurrent abdominal pain Tuberculosis Intestinal trouble Ulcer Hernia Bladder infection Kidney infection Kidney stones Protein or blood in urine Pilonidal cyst Serious skin disease Recurrent ear infections High Blood Pressure Anemia/ Low Iron Blood transfusion Chicken pox Diabetes Epilepsy /Seizures Malaria Mononucleosis (Mono) STD Severe menstrual cramps Sickle Cell Anemia Thyroid disorder Tumor/ cancer Chemotherapy/radiation Pain/Pressure in Chest Heart Disease Rheumatic fever Pneumonia Allergy injection If you answered yes to any of the above, please describe any that currently affect your current mental or physical health:Are there any activities you cannot participate in due to your health conditions?(e.g. If you cannot SCUBA due to recurrent ear infections)How physically active to you consider yourself?Exercise is defined here as engaging in an activity that raises your heart rate for 30 minutes or more at a time. Things like walking the dog, after school sports, hiking, mowing lawns and shoveling snow all count! Very Active (I exercise 5+ times/week) Active (I exercise 3-5 times/week) Somewhat Active (I exercise 1-3 times/week) I don't consider myself active Is there anything else to know about your health?
