Student Health History

Non-KWC Email

Mailing Address

Country

Street

City

Region

Postal Code

Cell Phone

Student Status

I am a continuing student

I am a new, transfer, or readmitted student

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

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

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.

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

Signature

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