Student Health History (U.S. Citizens Only)
Submission Date
12/2/2023
Last Name
guest
First Name
Middle Name
Current Age
Date of Birth
BC Student ID #
0
Citizen
Cell Phone
Home Phone
Gender
Address Line 1
Address Line 2
Address Line 3
City
State
Zip Code
Emergency Contact & Relationship
Name
Relationship
Address
Email Address
Phone
Personal History
History of injuries and/or operations (Give Nature and Year)
History of previous illness: (Provide Month and Year)
Appendicitis
Epilepsy
Pneumonia
Asthma
Kidney Diseases
Rheumatic Fever
Cardiac Condition
Malaria
Seasonal Allergies
Diabetes
Mononucleosis
Tuberculosis
Others
Do you struggle with depression, anxiety or feeling not like yourself?
Have you ever experienced any of the above feelings? If yes, when? Please explain.
Have you had any other severe illness NOT mentioned above? If so, please explain.
Have you ever used any psychoactive or addicting drugs without prescription?
Do you have a 504 or IEP? If YES, you must submit a completed health form signed by a medical professional.
Click here to download the Health Record Examination form.
Click the "Chose a file" button to upload your Health Record Examination form and any supporting documents.
Click the "Chose a file" button to upload Front of Insurance Card.
Click the "Chose a file" button to upload Back of Insurance Card.