1

All American Institute of Medical Sciences

Medical Education Par Excellence
66 High Street, Black River, St. Elizabeth, Jamaica, West Indies
Tel: 876 634 4062 Fax: 876 634 4109

Student Health Form

Year: 20__ Resident Commuter

This form is only for AAIMS University purposes and all information will remain confidential.

I. Students information

Name:
Last First Middle
Date of Birth: Gender: M F
(dd/mm/yyyy)
Program of study:
Person to call in emergency:
Persons Name: Phone #
Persons Name: Phone #

II. General Health Information:
1) Do you have any current disease(s)/medical disorder(s)? Yes No
2) Are you undergoing any treatment for any kind of chronic illness? Yes No
3) If yes, please indicate as per list below any diseases/conditions for which you are being treated.
Allergy/Hay Fever/Rhinosinusitis
Asthma
Arthritis/other Musculoskeletal problem..
Endocrine disorder: Diabetes, Thyroid problem..
Epilepsy
Hypertension
Heart Disease
Migraine/chronic headache
Panic disorder
Sickle cell or other blood disorder
Psychiatric specify..
Other specify------------------------------------------------------------------------------------------
Are you taking any medications (including oral contraceptives) on a regular basis?
Yes No
Please list all prescription medicines and the reason for taking medication
.
.



2



III. Please fill out the following information:

Doctors Name: _____________________________ Phone #:_____________ Fax #:____________
Address: ____________________________________________________________________________


Past History (Please check all that apply)
Surgery Type ______________________________ Year ________________
Hospitalizations Illness ______________________________ Year ________________
Psychological/Psychiatric : Diagnosis ____________________ Year _________________
Other _____________

Family History (Please check all disease/illness that apply)
Allergy: Asthma, Drug Hypersensitivity
Auto Immune Disease: Rheumatoid arthritis, SLE, other.
Heart Disease/Rheumatic Fever
Cancer
Haematological Disorder: sickle cell trait/disease, bleeding disorder
Hypertension
Endocrine disorder: Diabetes, Thyroid disorder, other.
Psychiatric: Depression, bipolar disorder, other
Neurological: Epilepsy, Fainting spells, Vertigo, other..
Eating Disorder/Obesity/Anorexia, other..
Other specify

Describe any special needs that the Health Service or the Counselling Centre can assist you with or that may
require follow up. If necessary, please attach medical verification.

Immunization Record:

Type Date (dd/mm/yyyy) Type Date(dd/mm/yyyy)
MMR Polio
DPT BCG
Tetanus Booster dose Hepatitis B
Mumps Measles
Rubella Meningococcal (if
given)


Physician / Family doctor assent:
I have verified all the information and it is accurate to best of my knowledge.

Name:

_____________________________________________________ Office Stamp here
Signature Date(dd/mm/yyyy)

3




IV. Student Declaration:

I assure that all responses made above are complete, true and accurate.
I understand that if there are any changes in my health status, I will contact AAIMS immediately.
I agree that I will be the responsible person for the above information and that failure to provide the correct
information may jeopardize my health status.
I agree to be responsible for any financial costs associated with any care. The AAIMS University is not
responsible for any such charges.

Student signature: ____________________

Date: ______________________________






























For Office Use only

Complete Incomplete
Signature __________________ Date __/__/______