MedicalHistoryForm-StudentHealthCenter：医学史的形式，学生健康中心.pdfVIP

Medical History Form Mail or fax to: The University of Alabama Student Health Center P.O. Box 870360 (205) 348-6262 Office (205) 348-0630 Fax Name________________________________________________________________ CWID____________________________ Date of Birth _______/_______/______ Last First Middle Permanent Address_________________________________________________________________________ Phone Number ____________________ ͆ Male Street City State Zip ͆ Female US Citizen Classification (circle one): Freshman/Sophomore/Junior/Senior/Graduate Student/Other ____________ I plan to enter UA: Fall/Spring/June/July Year______ ͆ Yes _____________________________ __________________ ___________________ ________________________________________________________ ͆ No Person to Notify in Emergency Relationship Phone Number Address City State Zip Do you have prescription insurance: Yes / No If yes: Will you be covered by a medical insurance policy while enrolled? Yes / No If yes: Name of Prescription Insurance_________________________ Name of Medical Insurance____________________________ Cardholder’s Name___________________________________ Personal Physician Phone Number_______________________ Cardholder’s Social Security#____________________________ Policy Holder’s Name_________________________________ Student’s relationship to cardholder________________________ Date of Birth________