Confidential Medical History Report

Student Information

First Name

Last Name

Birthdate

Email Address

Permanent Address

Country

Street

City

Region

Postal Code

Mobile Phone

Parent/Guardian Information

Parent/Guardian 1 Information

Relation to Student

First Name

Last Name

Resides with Student

Street

City

State

Zip

Primary Phone

Parent/Guardian 2 Information

Relation to Student

First Name

Last Name

Resides with Student

Street

City

State

Zip

Primary Phone

Health Insurance Information

NWU does not require that all student have insurance but it is strongly recommended. Student-Athletes will receive information about the insurance requirement for participating in NWU athletics.

Company Name

Policy Number

Primary Policy Holder Name

Please upload a copy of your insurance card

Upload another file?

Please upload a copy of your insurance card

Upload another file?

Please upload a copy of your insurance card

Immunizations

To ensure the health and safety of the NWU community with respect to communicable diseases, students are required to document that they have had the following vaccines :

Two MMR (Measles, Mumps, Rubella) vaccines
At least one Meningitis vaccination at or above age 16
Completed COVID-19 vaccination

A completed COVID-19 vaccination is defined as a single dose of the Janssen (Johnson & Johnson) vaccine or two doses of either the Pfizer or Moderna vaccine. Booster doses are recommended for those who are eligible.

Students with medical or religious reasons requesting exemption from this policy must submit the Student Vaccination Exemption Request form for approval.

Students who fail to provide the required immunization document during the first semester following admission to Nebraska Wesleyan University will be refused registration for the following semester unless a waiver form is signed.

Please attach immunization records below.

Upload another file?

Personal History

Allergic Reactions (Please list:)
(e.g. penicillin, sulfa, food, immunization, ASA, insect bites/stings)

Medical Conditions (Please list:)
(e.g. asthma, diabetes etc.)

Medical History (Please list:)
(e.g. surgeries, significant illness or injury, etc.)

Current Medications
(Rx and Over the counter)

Primary Care Physician

Do you currently have a Primary Care Physician?

Primary Care Physician

Address

Country

Street

City

Region

Postal Code

Phone Number

Emergency Instructions

Authorities at Nebraska Wesleyan University make every effort to contact parents or guardians in the case of a medical emergency. Do you have another person to contact in case of an emergency in addition to the parent/guardian(s) listed above, please provide their contact information below. (For example, a family member or friend who lives closer to NWU.)

Emergency Contact Information

Relation to Student

First Name

Last Name

Primary Phone

I give permission for authorities at Nebraska Wesleyan University to use their judgment in obtaining medical care for you? Select below:

I give permission for authorities at Nebraska Wesleyan University to use their judgment in obtaining medical care for my child? Select below:

Electronic Signature

By my signature, I confirm that I have read and understand the information on this form and I agree that all the preceding information is answered accurately and to the best of my knowledge. I understand that if I have fraudulently misrepresented information regarding any of the statements above, or the electronic signature, I am legally responsible and may be subject to the applicable penalties.

Electronic Signature

Date

Parent Electronic Signature (required if student is under 19)

Date

Nebraska Wesleyan University may use information in this form to provide you with medical treatment or services. We are required by law to maintain the confidentiality of information disclosed in counseling, and will not disclose such information to third parties without your written authorization except as may be required or allowed by applicable privacy laws.