Medical History
Please fill in our medical history form.
Student Name
Home Telephone
What is your gender?
Male
Female
Check the medical symptoms that you are currently experiencing:
Separate other symptoms by commas.
Chest pain
Respiratory
Cardiovascular
Hematological
Lymphatic
Neurological
Psychiatric
Gastrointestinal
Genitourinary
Weight gain
Weight loss
Musculoskeletal
Other:
Check the conditions that apply to you (student) or to any members of your immediate relatives:
Complete your medical history background with information related to your origins.
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Psychiatric disorders
Epilepsy
Diseases you had in childhood.
Chickenpox
Whooping cough
Erythema infectiosum
Three-day-fever (roseola infantum)
Hand, foot and mouth disease
Scarlet fever
Other:
Are you currently taking any medication? Please specify them here.
Do you have any allergies? Write them down here.
Separate allergies by commas.
Check if you are addicted to:
Cigarettes
Drugs
Alcohol
Caffeine
Submit the Medical History Form