Medical / Health Information

Last Name *

First Name *

Middle Name *

Date Of Birth *

Age *

Gender *

Marital Status *

Married

Single

Father's Name *

Father's Cell *

Mother's Name *

Mother's Cell *

Guardian (if other than parent)

General Wellness Questions

How would you rate your health? *

Do you handle stress well? *

Do you exercise on a regular basis? *

Are you often depressed about life? *

Do you become angry easily? *

Do you get along well with others? *

Identification Data

Height *

Weight *

Eye Color *

Hair Color *

Scars *

Birthmarks *

Do you wear glasses or contacts? *

Do you wear hearing aids? *

Medical Insurance

Are you covered by medical insurance? *

Yes

No

Insurance Company Name *

Insurance Company Address *

Policy Number *

Group Number *

Emergency Contact Information

Parent, guardian, spouse

Contact #1 Name *

Contact #1 Cell *

Contact #1 Work Phone *

Contact #1 Relationship *

Contact #2 Name

Contact #2 Cell

Contact #2 Work Phone

Contact #2 Relationship

Physician Information

Name of physician *

Physician's Phone Number *

Date of last physical *

Date of last Tetanus shot *

Tuberculosis Testing

Are you coming from another country to the United States? *

I have had a TB Test within the past 6 months *

TB Test Results *

A negative TB test result must be received before enrollment.

If positive, chest x-ray is required.

Chest X-Ray Result *

Have you ever used any illegal, injectable, or recreational drugs? *

Yes

No

Type of drug used: *

Approximate length of usage: *

When did you last use drugs? *

Have you ever used alcohol on a regular basis? *

Yes

No

Approximate length of alcohol usage: *

When did you last use alcohol? *

Have you ever used tobacco on a regular basis? *

Yes

No

Approximate length of tobacco use: *

When did you last use tobacco? *

Injuries or Surgeries

Have you had any injuries or surgeries? *

Yes

No

When and what was the injury and/or surgery? If multiple, please describe all of them. *

Allergies

Do you have any medicine allergies? *

Yes

No

List all medicines you are allergic to: *

What allergic reaction do you have when taking these medicines? *

Do you have any allergies to any environmental agents (pollen, dust, trees, latex, mold, etc.)? *

Yes

No

List your environmental allergies: *

What is your reaction to these environmental allergies? *

Does this require you to carry an Epi-pen? *

Do you have a food allergy or food-related disease? *

Yes

No

If yes, the Allergy Information Form is required to be filled out by your physician. (PDF form is located in the Additional Application Items email or you can contact HBBC for an emailed copy.)

List your food allergies: *

What allergic reaction do you have to this food? *

Does this food allergy require you to carry an Epi-pen? *

Chronic Illness

Do you have a chronic illness? *

Yes

No

Please explain: *

Are you currently or have you recently been under the care of a doctor? *

Yes

No

For what reason? *

Medication

Do you take any medicine on a regular basis? (insulin, Dilantin, allergy injections, etc.) *

Yes

No

Give complete information including name, dosage, and how often it is taken: *

Mental Health Problems

Has your job or schooling ever been interrupted because of a mental or emotional problems? *

Yes

No

How so? Please Explain. *

Have you ever been diagnosed with having an eating disorder such as Anorexia or Bulimia? *

Yes

No

When did you receive this diagnosis? Please explain.. *

Have you ever been hospitalized or treated with medication for anxiety, depression, or Psychosis? *

Yes

No

Please explain further. *

Limitations

Do you have a physical limitation? *

Yes

No

Please explain the physical limitation: *

Do you have a known learning disability? *

Yes

No

Please explain your learning disability: *

Will you need any exemptions or special exceptions from the rules of Heartland? *

Yes

No

Please explain what rules you need exemptions or special exceptions from and the reason why: *

Is there anything that would hinder you in pursuing a college career or living in the dorm? *

Yes

No

Please explain. *

Signature

The college reserves the right to require a doctor's physical examination or certain blood tests.

I hereby certify that the above information is complete and accurate to the best of my knowledge.

Sign Here *

Clear

Are you under the age of 18? *

Yes

No

Consent to Treat

This needs to be completed by your parent/guardian.

Student's Full Name *

I, the legal parent/guardian of the above student who is under the age of 18, hereby authorize medical treatment for my child in a case of emergency.

Signature of Parent/Guardian *

Clear

Meningococcal Vaccination Requirement

The state of Oklahoma has passed legislation that requires college students living in campus housing to be vaccinated against meningococcal disease or sign a waiver that they have received information about the disease and elected not to be Immunized.

This requirement MUST be met before the start of school.

My plan for the Meningococcal vaccination is to: *

For those choosing to have the vaccination, the vaccination form is required to be completed by your physician. (Documentation from a physician showing receipt of vaccine or copy of immunization record is also acceptable.)

A pdf form is available online or you may contact HBBC for an emailed copy.

Meningococcal Vaccination Waiver

To be completed by the individual requesting an exemption from the Requirement and their parent/guardian.

For individuals under the age of 18 years old.

Student's Full Name *

I am the parent or guardian of the above student. I have received the information provided by Heartland Baptist Bible College explaining the risks of meningococcal disease and am aware of the effectiveness and availability and cost of the vaccination at local health agencies. I am aware that meningococcal disease is rare, but a life-threatening illness. I understand that by law, Heartland policy requires that students residing in on campus housing for the first time be vaccinated against meningococcal disease. With this waiver, I seek exemption from this requirement. I voluntarily agree to release, discharge, indemnify, and hold harmless Heartland Baptist Bible College, its officers, employees, and agents from any and all costs, liabilities, expenses claims, or causes of action on account of any loss or personal injury that I might result from my decision not to be immunized against meningococcal disease.

Signature of Parent/Guardian *

Clear

Meningococcal Vaccination Requirement

The state of Oklahoma has passed legislation that requires college students living in campus housing to be vaccinated against meningococcal disease or sign a waiver that they have received information about the disease and elected not to be Immunized.

This requirement MUST be met before the start of school.

My plan for the Meningococcal vaccination is to: *

For those choosing to have the vaccination, the vaccination form is required to be completed by your physician. (Documentation from a physician showing receipt of vaccine or copy of immunization record is also acceptable.)

A pdf form is available online or you may contact HBBC for an emailed copy.

Meningococcal Vaccination Waiver

To be completed by the individual requesting an exemption from the Requirement.

For individuals 18 years of age or older:

I am 18 years of age or older. I have received the information provided by Heartland Baptist Bible College explaining the risks of meningococcal disease and am aware of the effectiveness and availability and cost of the vaccination at local health agencies. I am aware that meningococcal disease is rare, but a life-threatening illness. I understand that by law, Heartland policy requires that students residing in on campus housing for the first time be vaccinated against meningococcal disease. With this waiver, I seek exemption from this requirement. I voluntarily agree to release, discharge, indemnify, and hold harmless Heartland Baptist Bible College, its officers, employees, and agents from any and all costs, liabilities, expenses claims, or causes of action on account of any loss or personal injury that I might result from my decision not to be immunized against meningococcal disease.

Student Name *

Student's Signature *

Clear