HEALTH EVALUATION FORM Fall 2017 – Spring 2018 This form will be part of your health record while at PrattMWP and will be held at the Student Health Center. This form must be completed and returned to PrattMWP by Friday, June 30, 2017.

PERSONAL INFORMATION Last Name

First Name

Date of Birth

Gender

M.I.

Female

Male

Permanent Mailing Address

Trans

Preferred Name

Other:

Apt #

City

State

Zip Code

Country

Home Phone

Student Cell Phone

Parent Cell Phone

Ethnicity Caucasian

African American

Asian

Hispanic

Other:

CURRENT HEALTH CARE PROVIDER Name Address City

State

Zip

Phone

CONSENT TO PROVIDE MEDICAL CARE I hereby give permission to the PrattMWP Student Health Care Center Staff to examine/treat the student listed above for all medical problems/injuries while they are enrolled at PrattMWP. Student Signature: ______________________________________________________________________ Date: ________________________________________ Parent/Guardian Signature (only if under 18): ______________________________________

Date: _______________________________________

CONSENT TO ADMINISTER MEDICATION I hereby give permission to the PrattMWP Student Health Center Staff to administer the following non-prescription medications as directed by manufacturers’ instruction to my child in the event of illness and/or indicated symptoms:      

Tylenol-pain reliever/fever reducer Benadryl-allergy/cold symptoms Ibuprofen (Motrin, Advil) Sudafed PE-decongestant Tums/Antacid Exceptions:

Student Signature: _____________________________________________________________________

Date: ______________________________________

Parent/Guardian Signature (only if under 18): ______________________________________

Date: _______________________________________

Student Name: ________________________________________________________________________

Date of Birth: _____________________________

MEDICAL HISTORY Student Should Complete This Section Please indicate if you have experienced any of the following conditions within the last five years: ADHD/ADD Anemia Asthma Chicken pox Cerebral Palsy Depression Digestive trouble Hepatitis High cholesterol Peptic ulcer Pregnancy

Cancer or malignancy Chronic bronchitis/emphysema Diabetes Mellitus Dizziness/fainting Heart disease HIV/AIDS Phlebitis Rheumatic fever Menstrual problems High blood pressure

Seizure lupus Tobacco use Sleep problems Bipolar disorder Eating disorder Orthopedic problems Chronic kidney condition Blood disorders or bleeding trait Chronic Inflammatory bowel disease Anxiety or nervousness

Suicidal thoughts Migraine/recurrent headaches Hearing problems Autism Tuberculosis Chronic inflammatory bowel disease Removal of/damage to any organ Alcohol/drug use or addiction Arthritis Thyroid disorder

If yes to any of the above, please explain:

FAMILY MEDICAL HISTORY

ALLERGIES/ADVERSE REACTIONS

Please indicate if any of the following conditions apply to anyone in your family: Alcoholism or drug addiction Cancer Bleeding disorders Stroke Heart Disease Depression High blood pressure Anxiety Suicide Sudden death before 35 years Other:

Aspirin Penicillin Latex Food Insect/bee sting Sulfa Lidocaine/xylocaine X-ray contrast Other (specify): NO KNOWN ALLERGIES Please describe any allergic reactions:

CURRENT MEDICATIONS Please indicate if you take medication for any of the following conditions: NO CURRENT MEDICATION Acne Pain Headaches ADHD/ADD Anxiety Seizures Heart

Allergy Asthma Thyroid Blood Sugar (insulin) Blood pressure Allergy shoes Birth control Depression Other (specify):

Have you ever had surgery? Yes No If yes, please explain:

Please list the name and dosage for ALL current medications:

Have you ever been hospitalized? Yes No If yes, please explain:

Please return to: PrattMWP College of Art and Design Student Life Office 310 Genesee Street Utica, NY 13502 Fax: (315) 797-9349