International Student Health Information Form

Personal Information

Full Name Date of Birth Gender Female Male Other Nationality Student ID

Contact Information

Email Address Phone Number Current Address Emergency Contact Name Emergency Contact Phone Relationship to Emergency Contact

Health Insurance

Do you have health insurance? Yes No Insurance Provider Policy/ID Number

Medical History

Allergies Chronic Illnesses/Conditions Current Medications

Immunization History

Please list your immunizations

Additional Information

Dietary Restrictions Other Health Information