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Health Form
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Fields marked with an * are required
Student Information
Student Email Address *
First Name *
Middle Name
Last Name *
Birthdate *
Birthdate *
January
February
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1911
1910
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1908
1907
1906
1905
1904
1903
1902
1901
1900
Mailing Address *
Mailing Address *
Country
Street
City
Region
Postal Code
Student Cell Phone *
Gender
Student Type
Undergraduate (seeking Bachelor degree)
Graduate (seeking post Bachelor degree)
Student Term*
Fall 2022
Spring 2023
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 *
Mother
Father
Step-Mother
Step-Father
Legal Guardian
Aunt
Uncle
Grandmother
Grandfather
Sister
Brother
Spouse or Partner
Son
Daughter
Other
First Name *
Last Name *
Phone *
Email Address *
Should this person be contacted in the event of an emergency? *
Should this person be contacted in the event of an emergency? *
Yes
No
Add another emergency contact? *
Add another emergency contact? *
Yes
No
Relationship *
Mother
Father
Step-Mother
Step-Father
Legal Guardian
Aunt
Uncle
Grandmother
Grandfather
Sister
Brother
Spouse or Partner
Son
Daughter
Other
First Name *
Last Name *
Phone *
Email Address *
Should this person be contacted in the event of an emergency? *
Should this person be contacted in the event of an emergency? *
Yes
No
Add another parent/guardian? *
Add another parent/guardian? *
Yes
No
Relationship *
Mother
Father
Step-Mother
Step-Father
Legal Guardian
Aunt
Uncle
Grandmother
Grandfather
Sister
Brother
Spouse or Partner
Son
Daughter
Other
First Name *
Last Name *
Phone *
Email Address *
Should this person be contacted in the event of an emergency? *
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
Please check those you have experienced
Please check those you have experienced
Chicken Pox
Diphtheria
Hepatitis
Measles (Rubeola)
Measles (Rubella)
Mumps
Pneumonia
Rheumatic fever
Scarlet fever
Tonsillitis
Other
Chronic Diseases
Please check those you have experienced
Please check those you have experienced
Anemia
Anorexia/Bulimia
Arthritis
Asthma
Bleeding trait
Cancer or malignancy
Chronic bronchitis
Chronic skin disease
Convulsions or seizures (epilepsy
Diabetes
Diseases of the colon
Gallbladder/liver disease
Hay fever
Hearing problem
Heart disease
High Blood Pressure
Kidney disease
Malaria
Menstrual disorder
Orthopedic problem (i.e., knee, back)
Severe headaches
Sleep disorders
Speech
Thyroid or endocrine disturbance
Tuberculosis
Ulcer (stomach or duodenal)
Visual
Other
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
Please check those you have experienced
Anxiety
Depression
Eating Disorder
Substance dependence
Thoughts of harming self / others
Tuberculosis (TB) Screening Questionaire*
Have you ever had close contact with persons known or suspected to have active TB disease? *
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? *
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?) *
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? *
Have you been a volunteer or health care worker who served clients who are at increased risk for active TB disease? *
Yes
No
COVID-19 vaccination *
Have you recieved a COVID-19 vaccination?*
Have you recieved a COVID-19 vaccination?*
Yes
No
What type of COVID-19 vaccine did you receive?
What type of COVID-19 vaccine did you receive?
Pfizer
Moderna
Johnson & Johnson (J&J)
Other
Date(s) of your COVID-19 vaccination*
Immunization Record Upload
Are you a student athlete *
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
Submit