Study Abroad Student Medical Information Form
Personal Information
Full Name
Date of Birth
Student ID
Program Name
Emergency Contact Name & Relationship
Emergency Contact Phone
Medical Information
Primary Care Physician (Name & Phone)
Health Insurance Provider
Policy Number
Allergies (medications, foods, etc.)
Chronic Medical Conditions
Current Medications (name, dosage, frequency)
Recent Immunizations
Additional Information
Dietary Restrictions
Other Relevant Medical or Mental Health Information
Student Signature
Date