Health Form

Fields marked with an * are required

Student Information

Student Email Address *

First Name *

Middle Name

Last Name *

Birthdate *

Permanent Address *

Country

Street

City

Region

Postal Code

Student Cell Phone *

Gender

Student Type

Student Term*

Emergency Contact Information

Please list your emergency contact(s). This data will be used to provide contact information in the event of an emergency. Please list the contacts in the order you want them to be notified if an emergency arises. Clarke University will call those in the order listed until a person is reached.

Relationship *

First Name *

Last Name *

Phone *

Email Address *

Should this person be contacted in the event of an emergency? *

Yes

No

Add another emergency contact? *

Yes

No

Relationship *

First Name *

Last Name *

Phone *

Email Address *

Should this person be contacted in the event of an emergency? *

Yes

No

Add another parent/guardian? *

Yes

No

Relationship *

First Name *

Last Name *

Phone *

Email Address *

Should this person be contacted in the event of an emergency? *

Yes

No

Health Insurance Coverage

Insurance Company *

Insurance Phone Number *

Policy Number *

Primary/Parent Carrier (Policyholder) *

If HMO or PPO, list approved hospital/physician providers in Dubuque

Personal Health Information

Acute Infectious Diseases

Chronic Diseases

Allergies*

None

I have allergies

Please list any allergies to medications, food and environment - separated by commas *

Medications

List all medications prescribed by physician/psychiatrist. - separated by commas

Mental or Emotional concerns

Please check those you have experienced

Tuberculosis (TB) Screening Questionaire*

Have you ever had close contact with persons known or suspected to have active TB disease? *

Yes

No

Have you traveled to one or more countries or territories that have a high prevalence of TB disease? *

Yes

No

Have you been a resident and/or worked in a high-risk setting? (i.e. correctional facility, long-term care facility, homeless shelter?) *

Yes

No

Have you been a volunteer or health care worker who served clients who are at increased risk for active TB disease? *

Yes

No

Immunization Record Upload

Are you a student athlete *

Yes

No

All student athletes must have a current physical dated after June 1 of the current academic year. The form is located at clarke.edu/studentathlete/forms.

Fill out Medical History Form, Athletic Insurance Form, and submit Physical and Insurance Card.

Thank you for providing this information. If you need to make any changes or updates, please contact the Student Life Office at (563)588-6313