Student Medical Form
A student medical form is required to be filled by students who are applying for under graduate or graduate studies in colleges or universities. This type of medical form is also applicable when students require specific medical aid or are admitted into the emergency ward in a hospital. The information provided in the student medical form assists in proper health care and diagnosis of medical conditions.
You can Download the Free Student Medical Form, customize it according to your needs and Print.Student Medical Form is either in MS Word, Excel or in PDF.
Sample Student Medical Form
Student Medical Form
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Student Medical Form |
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| As a registered ABC College student, you can avail of several services of the ABC College Medical free of charge. This is covered under the ABC College Student Medical Plan. In order to avail these medical services, please fill the form carefully. | |||
| Name of the Student___________________________________
Last Name First Name |
Street Address | ||
| City/State/Zip | Phone | ||
| Gender | Date of Birth | ||
| Age | |||
| Family Medical History | |||
| Health – Good/Bad | List Health Problems | Deceased/Age | |
| Father | |||
| Mother | |||
| Brother (s) | |||
| Sister (s) | |||
| Student Medical History | |
| List all medications that have been prescribed to you and that you are currently taking. (This includes over-the-counter medications, herbal medications, vitamins, and other supplements). | |
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| History of any serious illness or any injury in the recent past. Please mention the medication or treatment prescribed for the same. | |
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| History of any hospitalization or surgery. Please mention the dates for hospitalization or surgery and duration of stay. | |
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| List any medication that you are allergic to | |
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| List food or environmental allergies and their corresponding reactions | |
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| Describe your present health condition. Mention any medication prescribed. | |
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| Do you wear glasses or contact lenses?Yes No | Do you smoke?Yes No |
| Do you drink alcoholic beverages?Yes No | Do you take sleeping pills or medication?Yes No |
| All the above information provided are correct to the best of my knowledge………………………………………….
Student signature Date |
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Category: Medical Forms
