AUN Health Information Form
STRICTLY CONFIDENTIAL
First Name
Your answer
Middle Name
Your answer
Last Name
Your answer
Please specify the category
AUN ID number
Your answer
Home Address (number & street)
Your answer
City or Town
Your answer
State
Your answer
Nationality
Your answer
Occupation
Your answer
E-mail
Your answer
Phone Number
Your answer
Birthdate
MM
/
DD
/
YYYY
Gender
Marital Status
Whom to notify in case of emergency
Name
Your answer
Whom to notify in case of emergency
Address
Your answer
Whom to notify in case of emergency
Phone Number
Your answer
Family Physician's Name
Your answer
Family Physician's Name
Address
Your answer
Family Physician's Name
Phone Number
Your answer
Current/chronic medical conditions
Your answer
Past medical conditions
Your answer
Infectious desease record
Your answer
Surgical history
Your answer
Serious injuries
Your answer
Current medications
Your answer
Do you smoke cigarettes?
If so how many per day?
Your answer
Do you drink alcohol?
Allergies
Specify
Your answer
Family health history
Health evaluation
Height
Your answer
Health evaluation
Weight
Your answer
Health evaluation
Blood group
Your answer
Health evaluation
Genotype
Your answer
Vaccination status
State if vaccinated recently
Your answer
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