Health History

All students are required to file a current health record with Welch College at the time of enrollment. This information is confidential. All sections must be filled out to be considered complete.

Check all that apply:*
- Undergrad
- Nursing
- TE
- Dorm
- Commuter
- Graduate Program
Name
First Middle Last
Gender*
Home Phone*
Cell Phone*
Email*
Social Security #*
Birth Date*
Initial Enrollment Term*
Emergency Contact*
First Last
Emergency Contact Person is:*
Emergency Contact Home Phone*
Emergency Contact Cell Phone*
Emergency Contact Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Health Insurance Information
Please provide copy of Insurance Card
I am currently covered by health insurance
*
- Yes
- No
Name of Insurance Company*
Insurance Company Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Insurance Company Phone Number*
Subscriber's Name*
Subscriber's relation to Student*
Policy/ID No.*
Group No.*
Plan No. (if applicable)
Medical History
have you had or are you experiencing any of the following? (Please explain below)
Check all that apply:*
- Rheumatic Fever
- Anemia
- Cancer
- Heart Trouble
- Broken Bones
- Tonsillitis
- Difficulty with Eyes
- Asthma
- Chest Pain
- Pneumonia
- Hay Fever
- Jaundice
- High Blood Pressure
- Chicken Pox
- Malaria
- Frequent Headaches
- Whooping Cough
- Tuberculosis
- Seizures
- Head Injury
- Liver Disease
- Joint Trouble
- Chronic Cough
- Emotional Problems/Disorders
- Ear Infection
- Measles
- Pleurisy
- Stomach Trouble
- Back Trouble
- Skin Trouble
- Foot Trouble
- Influenza
- Scarlet Fever
- Sinus Trouble
- Mumps
- Glasses/Contacts
- Kidney/Bladder/Urinary Tract Infections
- Diabetes Type I/II/or pregnancy induced
- Mononucleosis
- Other
- None of the Above
Surgeries, Special Procedures, &/or Medical Treatment of Any Kind (Explain type and dates)
Please explain any item marked above:
Please provide allergies or sensitivities
Medications You are Taking Regularly
List all prescribed and over the counter medications, including vitamins &/or herbs, body enhancing formulas, and diet pills
Please include name, dosage, frequency and reason for each medication.
Family History
Has anyone had or does anyone have any of the following in your immediate family: (Please explain below)
- Tuberculosis
- Epilepsy
- Asthma
- Allergies
- Cancer
- High Blood Pressure
- Heart Disease
- Diabetes/Type I/II/Pregnancy Induced
- Other
Explain:
Have you traveled or lived outside of the United States?*
If yes, list location and dates
Health Form Agreement
I affirm that any optional information withheld or erroneously reported will make it difficult to receive effective medical treatment and I therefore waive any liability on the part of Welch College related to absence or error in such information.
Type YES in box if you are in agreement of above statement
Today's Date

Welch College does not discriminate on the basis of race, gender, color, national and ethnic origin, age, or disability in admitting students or in otherwise administering its educational policies and school-sponsored programs.

Health Insurance Information

Medical History

Medications You are Taking Regularly

Family History

Health Form Agreement