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UNIVERSITY OF THE NATIONS

KONA, HAWAII

ON

STUDENT HEALTH FORM

Identity:
Last name:_________________________________________ First name:____________________________________ MIddle:__________
Home phone:____________________ Email:___________________________________________________________________________
Medical information:
Name of insurance carrier:____________________________________________________ Contact phone:_________________________
Policy type:___________________________________ Policy number:__________________ Expiration date: D______M______Y_______
Brief description of coverage:________________________________________________________________________________________
In case of emergency contact:________________________________________________________ Relationship:_____________________
Street/Box:________________________________________________________________________ Phone:_________________________
City/Town:___________________________________ State:_________________ Zip:_____________ Country:______________________
Health history: (Answer all questions. Explain positive answers below or on a separate piece of paper.)
Do you now have, or have you ever had, any of the following?
Yes No
[ ] [ ] 1-Skin condition
[ ] [ ] 2-Eye trouble
[ ] [ ] 3-Ear trouble
[ ] [ ] 4-Head injury
[ ] [ ] 5-Recurrent headache
[ ] [ ] 6-Epilepsy
[ ] [ ] 7-Fainting spells
[ ] [ ] 8-Mental/Nervous disorders
[ ] [ ] 9-Depression
[ ] [ ] 10-Paralysis
[ ] [ ] 11-Insomnia
[ ] [ ] 12-Shortness of breath
[ ] [ ] 13-Hay fever/Asthma
[ ] [ ] 14-Allergies
Specify:__________________________

Yes No
[ ] [ ] 15-Heart trouble
[ ] [ ] 16-High blood pressure
[ ] [ ] 17-Low blood pressure
[ ] [ ] 18-Rheumatism/Arthritis
[ ] [ ] 19-Back problems
[ ] [ ] 20-Dislocation of joints
[ ] [ ] 21-Broken bones
[ ] [ ] 22-Stomach/Duodenal ulcer
[ ] [ ] 23-Sexually transmitted disease
[ ] [ ] 24-Surgery
[ ] [ ]
Appendectomy
[ ] [ ]
Tonsillectomy
[ ] [ ]
Hernia repair
[ ] [ ]
Other
Specify:__________________________

Yes No
[ ] [ ] 25-Jaundice
[ ] [ ] 26-Hepatitis
[ ] [ ] 27-Intestinal troubles
[ ] [ ] 28-Recurrent diarrhea
[ ] [ ] 29-Diabetes
[ ] [ ] 30-Kidney disease
[ ] [ ] 31-Anemia
[ ] [ ] 32-Gall bladder problems
[ ] [ ] 33-Cancer/Tumors
[ ] [ ] 34-Female conditions
[ ] [ ]
Irregular periods
[ ] [ ]
Severe cramps
[ ] [ ]
Excessive flow
[ ] [ ]
Now pregnant
Other:______________________________

Other illnesses or conditions:________________________________________________________________________________________

Explanations for above:_____________________________________________________________________________________________
________________________________________________________________________________________________________________
Are you presently under a doctors care? [ ]Yes [ ]No Specify:_____________________________________________________________
Are you presently taking any medication? [ ]Yes [ ]No Specify:_____________________________________________________________
Are you allergic to any drugs/medications? [ ]Yes [ ]No Specify:_____________________________________________________________
Are you now receiving or did you ever receive compensation for disability from any source? [ ]Yes [ ]No Specify:_____________________
________________________________________________________________________________________________________________
Do you have any physical impairments, handicaps or health conditions which require special attention? [ ]Yes [ ]No Specify:___________________
________________________________________________________________________________________________________________
How would you rate your overall health condition? [ ]Excellent [ ]Good [ ]Fair [ ]Poor

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Disease history:
Have you ever had any of the following COMMUNICABLE DISEASES?
Yes No
[ ] [ ]
[ ] [ ]
[ ] [ ]
[ ] [ ]

Yes No
[ ] [ ] 5-Pertussis
[ ] [ ] 6-Scarlet fever
[ ] [ ] 7-Tuberculosis
[ ] [ ] 8-Other

1-Chickenpox
2-Measles (rubella)
3-Measles (rubeola)
4-Mumps

Family history:
Have any of your immediate family members ever had any of the following?
Yes No
[ ] [ ]
[ ] [ ]
[ ] [ ]
[ ] [ ]
[ ] [ ]

Yes No
[ ] [ ] 6-Arthritis
[ ] [ ] 7-Stomach disease
[ ] [ ] 8-Asthma/Hay fever
[ ] [ ] 9-Epilepsy/Convulsions
[ ] [ ] 10-Cancer

1-Tuberculosis
2-Diabetes
3-Kidney disease
4-Heart disease
5-Hypertension

Immunizations:
DISEASE
1st dose

BASIC (year)
2nd dose

3rd dose

1st dose

BOOSTER (year)
2nd dose
3rd dose

Diphtheria:

________

________

________

________

________

________

Tetanus:

________

________

________

________

________

________

Pertussis:

________

________

________

________

________

________

Polio:

________

________

________

________

________

________

Rubella:

________

________

________

________

________

________

Mumps:

________

________

________

________

________

________

Hepatitis A:

________

________

________

________

________

________

Hepatitis B:

________

________

________

________

________

________

University of the Nations is a degree granting institution (Associate, Bachelor and Master). UNIVERSITY OF THE NATIONS
IS NOT ACCREDITED BY AN ACCREDITING AGENCY RECOGNIZED BY THE UNITED STATES SECRETARY OF EDUCATION.
Please mail all forms to:
Admissions Office, #434
University of the Nations
75-5851 Kuakini Highway
Kailua Kona, Hawaii 96740-2199

University of the Nations (U of N) admits students of any race, color,

national and ethnic origin to all the rights, privileges, programs and activities
generally accorded or made available to students at the school. It does
not discriminate on the basis of race, color, national and ethnic origin in
administration of its educational policies, admissions policies and schooladministered programs.

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Phone: 808-326-4433
Fax: 808-326-4454
Email: admissions@uofnkona.edu

1205 SHF