Health History Questionnaire
Your responses to the questionnaire will be kept confidential.

Student First Name *
Your answer
Student Last Name *
Your answer
Gender *
Birthdate *
MM
/
DD
/
YYYY
Birth Place *
Your answer
Date entered U.S. if not born in U. S
Please Note: Documentation is required from a U.S. health care provider for Tuberculosis testing results if born outside the U.S. or been outside the U.S. within the last five years.
MM
/
DD
/
YYYY
Mother Name *
Your answer
Father Name *
Your answer
With whom does the child live? *
Who is the legal guardian? *
Your answer
Please list each family member name, birthyear, gender including each parent/guardian and all children *
Please hit enter after each family member so they are each on their own line.
Your answer
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