Complete the following form and store it in a safe place in your dorm room/apartment. Make sure a trusted friend or roommate knows about this sheet and its location in case of an emergency. (Download the pdf version of our College Emergency Contact & Information.)
Download the free My Personal Medication Record pdf from the AARP in English or Spanish. Also, along with your medical history, print out our Medical Appointment Tracking Form to take to each doctor or medical appointment. After each appointment, add all medical notes to your personal medical folder.
WHN TIP – Go Digital: Save your medical history and contact information to a flash drive or the cloud where it can be easily accessed.
College Emergency Contact & Information Sheet
Your Name________________________________________
Address_____________________________________________________
Phone Number________________________________________________
Date of Birth__________________________________________________
Social Security Number___________________________________________
Emergency Contact (home/work phone and relationship)_______________________________________________
Emergency Contact (home/work phone and relationship)_______________________________________________
Health Insurance Information
Company___________________________________________________
Phone_____________________________________________________
Policy Holder’s Name___________________________________________
Policy Number________________________________________________
Your Medical History (date and nature of illnesses, surgeries)
Illness and Date________________________________________________
Illness and Date________________________________________________
Illness and Date________________________________________________
Illness and Date________________________________________________
Allergies_____________________________________________________
Health Conditions______________________________________________
Current Medications_____________________________________________
____________________________________________________________
____________________________________________________________
Vaccinations
Talk to your school’s health services about health requirements. Not all listed vaccinations are required or necessary to have more than once. Also, if you plan to travel abroad during college you may need extra vaccinations and/or documentation of vaccinations.
Type Date #1 Date #2 Date #3 Date #4
Chickenpox (Varicella) ______________________________________________
DTP ______________________________________________
(Diphtheria, Tetanus, Pertussis)
Hepatitis A ______________________________________________
Hepatitis B ______________________________________________
Influenza ______________________________________________
Meningococcus ______________________________________________
MMR ______________________________________________
(Measles, Mumps, Rubella)
Polio ______________________________________________
Rabies ______________________________________________
Tetanus ______________________________________________
COVID 19 ______________________________________________
Other ______________________________________________
Tuberculosis (test)
Date: Results:
__________________________________________________________
Date: Results
__________________________________________________________
Remember…
The information provided here is not meant to be a substitute for professional medical advice. These tips are from doctors, nurses and people who have shared their real-life advice; always check with a doctor or other appropriate medical professional you trust before making any healthcare changes.
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