Health History Lang Wellness Center Health Documents

Lang Wellness Center Health History

The following form will be used to send secure HIPAA compliant documents to the Rockford University Lang Wellness Center.
Due date for students starting in the Fall Semester:

September 1

Due date for students starting in the Spring Semester:

February 1
Full Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Rockford University Email*
example@Rockford.edu

PLEASE LIST ANY MEDICATIONS (including birth control and mental health medication)THAT YOU ARE CURRENTLY TAKING:

If you have medical or psychological needs requiring academic or housing accommodations, you must request a meeting with the Disability Support Services Coordinator at Lang Wellness Center by emailing healthcenter@rockford.edu.
I hereby state that my answers on this health history form are complete and accurate:*

Clear
Signature of parent or guardian if under 18 years old

Clear
Lang Wellness Center

5050 East State Street

Rockford, IL 61108

phone 815-226-4083 fax 815-226-3335

HealthCenter@Rockford.edu
Should be Empty:

	Yes	No
Does anyone in your family have or have they ever had high blood pressure?
Does anyone in your family have or have they ever had heart disease (including heart attack or congenital disorders)?
Does anyone in your family have or have they ever had diabetes?
Does anyone in your family have or have they ever had Asthma?
Does anyone in your family have or have they ever had Sickle Cell Anemia?

	Yes	No
Do you use tobacco products (cigarettes, cigars, snuff/chewing tobacco)?
Do you usually drink more than 4 or 5 drinks containing alcohol in one social session?
Have you felt you ought to cut down on your drinking?
Do you use marijuana, or any other street or recreational drugs? If yes, please explain below.
Are sexually transmitted infections or pregnancy prevention a concern?
Do you have concerns about your weight?
Are you on a special diet or taking any supplements? If yes, list below.
Would you like to discuss any concerns about your lifestyle with a nurse at Lang Wellness Center?

	Yes	No
Have you felt anxious much of the time in the past year? If so, have you received counseling and /or medication? Please explain below.
Have you felt sad or depressed much of the time in the past year? If so, have you received counseling and/or medication? Please explain below.
Has anyone ever sexually, physically or emotionally abused you (including repeated hitting, name-calling, or loud criticism; childhood sexual touching by someone older than you; or rape)?
Are you in a relationship with a person who physically hurts or threatens you?
Do you feel afraid of your partner?
Do you have concerns regarding sexuality?
Do you have concerns regarding gender orientation?
Would you like to discuss any concerns with a confidential , licensed counselor at Lang Wellness Center?

	Yes	No
Has a doctor ever denied or restricted your participation in sports for any reason?
Have your ever passed out or nearly passed out during or after exercise?
Have you ever had discomfort, pain, tightness or pressure in your chest during exercise?
Does your heart ever race or skip beats (irregular beats) during exercise?
Do you have frequent muscle cramps when exercising?
Would you like to discuss any concerns about your exercise history with a nurse at Lang Wellness Center?

Lang Wellness Center Health History