Health History

Gender(Required)

Home Phone(Required)

Cell Phone(Required)

Email(Required)

Social Security #(Required)

Birth Date(Required)

Initial Enrollment Term(Required)

Emergency Contact Person is:(Required)

Emergency Contact Home Phone(Required)

Emergency Contact Cell Phone(Required)

Health Insurance Information

Please provide copy of Insurance Card

I am currently covered by health insurance

Name of Insurance Company(Required)

Insurance Company Phone Number(Required)

Subscriber's Name(Required)

Subscriber's relation to Student(Required)

Policy/ID No.(Required)

Group No.(Required)

Plan No. (if applicable)

Medical History

have you had or are you experiencing any of the following? (Please explain below)

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

Explain:

Have you traveled or lived outside of the United States?(Required)

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

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