CONFIDENTIAL HEALTH HISTORY QUESTIONNAIRE

University of Nevada, Las Vegas, Office of International Programs

 

Last Name:  ____________________________  First Name:  ___________________________

 

Birthdate:  _________________________  Program Name:  _____________________________

 

Year:  ________________                   Summer        Fall              Spring

 

EMERGENCY CONTACT:  Please identify a person or persons (parents, guardian, etc.) who is to be informed in the event of any emergency. By completing this section, I hereby give UNLV permission to contact the person listed in the event of an emergency.

 

Name:  __________________________________  Relationship: ______________________

 

Address:  __________________________________________________________________

 

Phone #:  __________________________________________________

The purpose of this form is to help UNLV to be of assistance to you should the need arise during your study abroad experience.  Mild physical or psychological disorders can become serious under the stresses of life while studying abroad.  It is important that the program be made aware of any medical or emotional problems, past or current, which might affect you in a foreign study context.  The information you provide will remain confidential and will be shared with program staff, faculty, or appropriate professionals only if pertinent to your own well being.  UNLV may not be able to accommodate all individual needs or circumstances.  The information does not affect you admission to the program. 

 

MEDICAL HISTORY

 

Yes  No   1.  Are you generally in good physical condition? (If no, please explain.)

 

Yes  No   2.  Have you ever been treated or are you currently being treated for any psychological or emotional problems? (If yes, please explain.)

 

Yes  No   3.  Do you have any allergies to drugs or foods? (If yes, please explain.)

 

Yes  No   4.  Are you taking any medications?  (If yes, please explain.)

 

Yes  No   5.  Have you had any major injuries, disease or ailments in the past five years?  (If yes, please explain.)

 

Yes  No   6.  Are you a vegetarian or are you on a restricted diet?  (If yes, please explain.)

 

Yes  No   7.  Is there any additional information (concerning medical conditions or mental, learning, or physical disabilities) that would require accommodation or be helpful for the program to be aware of during your study abroad experience?  (If yes, please explain.)

 

 

_______________________________________      __________________________________________

Student Signature                                                                      Date