International Student Health Services

Student Health Services - International Student Health Form

Before You Begin:

All information must be in English
You will need your Benedictine student ID number. If you don't know what your ID number is, please contact the International Programs and Services department at (630) 829-6304
You will also need to have an electronic version of your completed immunization records if you want to include them with this health form (saved as either a PDF, Word, or Excel document). You can also scan a physical copy of your immunization records to your computer and upload it.
This form must be completed and your immunization record submitted before the first day of class for the semester
You are required to have completed the immunization and tuberculin testing requirements prior to your arrival on campus.
All students are required to complete this form. All information is confidential and for Student Health Services use only

Note: To save yourself time and effort, the Student Health Services office highly recommends obtaining an electronic copy of your immunization records before completing this form. Then you can upload the file with this form. The information will be reviewed by the Student Health Services staff for Illinois State Compliance. If you want a blank copy of Benedictine University's Immunization Record document, you can download here.

Important - due to security and privacy concerns, immunization records sent as email attachments will not be accepted; the email will be immediately deleted without opening and your immunization records will still be listed as incomplete.

Year and Term of Entry*

Student Type*

Commuter Resident

Gender*

Male Female

Program*

Undergraduate Graduate

Personal History

All information must be in English.

Student's Full Name*

First Name

Middle Name

Last Name

Local US Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Date of Birth*

Student ID Number*

Please enter only the seven numbers. Do not include the leading B

Student's Phone (Local)*

Name of First Parent, Guardian, or Spouse *

First Name

Last Name

Name of Second Parent or Guardian

First Name

Last Name

Emergency Contact Name*

First Name

Last Name

Emergency Contact: Primary Phone*

Emergency Contact: Secondary Phone

BenU Email

Medical History

Are you allergic to any medication or food?*

Yes No

If yes, please list them by name*

Are you taking any medications (including oral contreceptives) on a regular basis?*

Yes No

If yes, please list all prescriptions by name and the reason for taking them*

Do you currently have an illness or disability that requires medical treatment?*

Yes No

If yes, please list (e.g. diabetes, seizure disorder, heart condition, ADD/ADHD, anxiety/depression, asthma, etc.)*

Have you had any major illnesses (medical, surgical, or psychiatric) in the past?*

Yes No

If yes, please list any hospitalization or operations*

Do you have any environmental allergies?*

Yes No

If yes, please list*

Family History

Father's Age*

Father's Health Status*

If no longer living, cause of death (Father)

Mother's Age*

Mother's Health Status*

If no longer living, cause of death (Mother)

Sibling(s) Age(s)*

Enter "N/A" if you don't have any siblings

Sibling(s) Health Status(es)*

Enter "N/A" if you don't have any siblings

If no longer living, cause of death (Siblings)

Consent for Emergency Treatment

I consent to medical care and/or emergency treatment while I am enrolled as a student at Benedictine University. Care will be determined on the judgment of the doctors or nurses selected by the University. I agree to be responsible for any financial costs associated with any of the above mentioned care.

Signature Date*

Are you 18 years of age or older as of today

Yes No

Student's Name*

First Name

Last Name

Student's Signature (must be 18 or older)*

[clear]

Use your mouse or finger to draw your signature above

Parent or Guardian's Name (if student is under 18)*

First Name

Last Name

Parent or Guardian's Signature (if student is under 18)*

[clear]

Use your mouse or finger to draw your signature above

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