International Student Medical Information Form
Full Name
Date of Birth
Student ID
Gender
Male
Female
Other
Nationality
Contact Information
Email
Phone
Permanent Address
Emergency Contact Name & Relationship
Emergency Contact Phone
Emergency Contact Email
Medical Information
Medical History (illnesses, surgeries, hospitalizations)
Allergies
Current Medications
Chronic Conditions / Disabilities
Immunizations (list vaccines & dates or attach record)
Health Insurance Provider & Policy Number
Primary Physician Name & Contact
Other Relevant Medical Information
Consent & Declaration
I certify that the information provided is true and complete to the best of my knowledge.
Signature
Date