Medical History Form

INSTRUCTIONS AND INFORMATION:

1. 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.
2. 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.
3. 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.
4. Send completed forms to: Office of Admissions

Kentucky State University

ASB Suite 312

400 E. Main St.

Frankfort, KY 40601

Fax: (502) 597-5814

IDENTIFICATION

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