Student Health Form

Non-KWC Email*

Cell Phone*

Student Status*

I am a continuing student

I am a new, transfer, or readmitted student

KWC Student ID Number*
Please include all the digits of your ID Number. Your ID Number can be found on your student ID.

Have any of the following changed? Check all that apply.*

I have had a change in my health history

I have had a change in my emergency contact information

I have a change in my personal information i.e. address, marital status, etc.

I have a change in insurance coverage

Social Security Number*

Gender*

Female

Male

Non-Binary

Prefer not to answer

Emergency Contact Information

Relationship Type

Emergency Contact

First Name*

Last Name*

Relationship Type*

Emergency Contact Primary Address*

Country

Street

City

Region

Postal Code

Emergency Contact Phone Number*

Health Information and History

Height*
Please indicate the units of measure. For example, 5'9" or 175 cm.

Weight*
Please include the units of measure. For example, 150 lbs or 68 kg.

Do you take medications regularly?*

Yes

No

Please list all medications*

Please list all medications to which you have allergies.*
If you are not allergic to any medications, please type N/A.

Please explain any issues you checked above*

Immunization Information

Are your immunizations up to date?*

Yes

No

Immunization records are required to be on file in the Office of Student Health Services. Do you have your immunization records available to submit with this form?*

Yes

No

Immunization Records

It is your responsibility to provide immunization records to the Office of Student Health Services before beginning classes. They can be uploaded, mailed to the College, emailed to healthservices@kwc.edu.

Meningitis Vaccine Information

Pursuant to Kentucky Legislature House Bill 342 that became effective July 1, 2004, Kentucky educational institutions of higher learning that provide residential housing are required to provide information regarding meningitis to full-time students living in residential housing. Bacterial meningitis is a rare but potentially fatal disease. It is caused by a bacterial infection that may cause severe inflammation of the brain and spinal cord. Adverse side effects might include brain damage, hearing loss and/or loss of limbs. College students who live in dormitories are at a slightly increased risk for contracting meningococcal disease than the general population.

Meningitis Vaccination Acknowledgment*

I have received a meningitis vaccination

I have not received a meningitis vaccination and do not wish to be vaccinated

I have not received a meningitis vaccination but would like to be vaccinated

Should you be interested in the vaccine, please see your primary care provider.

Insurance Coverage

Do you have health insurance coverage?*

Yes

No

Student insurance coverage information is required to be on file in the Office of Student Health Services. Do you have your insurance coverage information available to submit with this form?*

Yes

No

Front of Insurance Card

Back of Insurance Card

Acknowledgement

I have reviewed information listed on this form or I acknowledge that there are no changes to my personal information. I understand that by completing this health form, information may be shared with Kentucky Wesleyan College's physicians, nurses, and mental health counselors. Furthermore, I acknowledge that all information supplied on this form is current and correct to the best of my knowledge.

Yes

Full Name