Medical History Form
We recommend this form be returned to the address below within 30 days or no later than 14 days prior to enrollment. All pages must be completed.
We recommend this form be completed by all new students and students who have been away from the University for more than 10 months. We also recommend students entering graduate school complete this form.
Information on this form is CONFIDENTIAL, is for Kentucky State University Student Health Services, will not be released without the student's consent, and will not affect admissions status.
Send completed forms to: Office of Admissions
Kentucky State University
ASB Suite 312
400 E. Main St.
Frankfort, KY 40601
Fax: (502) 597-5814
ID Number (see acceptance letter): ___
Name (last, first, middle)
Home Address (number and street)
City State
Zip Code Country
Home Telephone: (_____)
Cell Phone: (___)
Email: ___
Date of Birth (Month-Day-Year): ___
Sex (optional): ☐ Male
Female
Emergency Contact: ___
Emergency Contact Phone Number: (____) _____
Rev 2/22/16