Semester

Academic Year for which you are applying

Gender

Home Institution

Email

PERSONAL HISTORY

Please check if you have or have had any of the following:

Personal Habits

Please list any habits that may affect your health (i.e., tobacco, alcohol, etc.)

Other

If you checked other for any of the above categories, please explain below.

FAMILY HISTORY

Please fill out your family history as it relates to the state of their health.

Age of father

If deceased or if unknown, please write Not applicable.

State of your father's health

Age of mother

State of your mother's health

Age of first sibling

If deceased or if unknown, please write Not applicable.

State of your first sibling's health

Age of second sibling

If deceased or if unknown, please write Not applicable.

State of your second sibling's health

Age of third sibling

If deceased or if unknown, please write Not applicable.

State of your third sibling's health

Additional comments about family history

REVIEW OF PAST ILLNESSES OR SYMPTOMS

Please complete the following. Do not leave any questions blank.

Has your physical activity been restricted in the past five years?

If yes, please fill out the next section.

If yes to the above, give reasons and duration.

Have you consulted or been treated by a clinic, physician, or other practitioners within the past five years, other than routine check ups?

If yes, please fill out the next section.

If yes, give reason(s) and year(s).

Have you ever been hospitalized?

If yes, please fill out the next section.

If yes, please explain the illness.

Do you have any chronic/recurrent illness?

If yes, please fill out the next section.

If yes, what is your chronic/recurrent illness?

Have you had any allergic reactions to prescription or over-the-counter medications?

If yes, please fill out the next section.

If yes, which medication(s)?

Have you received counseling or mental health treatment within the last three years?

If yes, please fill out the next two questions.

Please describe current treatment and/or medications. (This information will be kept confidential. It will only be used to provide help needed in Cordoba.)

You will need to have a mental health professional or counselor fill out an additional form.

If yes, have you discussed with your mental health counselor the idea of continuing or leaving therapy while you are abroad?

If yes, please fill out the next section.

Signature

Student Medical History Form