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Health History Form

The primary purpose of this form is to ensure that medical records are current. It also provides a means of identifying students with special needs and a historical basis for the provision of health care. This information is confidential. These records will not be released without the student’s written consent and will not affect admission status.

If you will be an athlete, you must fill out additional required health history and vaccination forms.

Part I

Emergency Contact

Primary Physician

Personal Medical History

Indicate current illness or history of any of the following. Detail any positive answers or health problems that may require treatment while at Notre Dame.

PART II: Parental consent to medical and/or surgical treatment of minor

This section is to be completed by the parent or guardian of any student who will be younger than 18 upon arrival on campus.

The laws of Maryland require that surgical and medical treatment of minors and release of medical information to hospitals, other physicians and insurance companies about conditions treated by us be at the request of and with the approval of their parents. This right to request and approval may be delegated to University officials. Although it is our policy to notify the parents as soon as possible in the event of major illness or injury, it is impractical to notify them for every minor illness or injury requiring treatment. It will help us protect the health of your child if you will delegate to us discretion in these matters.