Health History

SPIRIT OF HOUSTON
2017-2018

As a member of the SPIRIT OF HOUSTON, health is of utmost importance to us.

It is a REQUIREMENT that you complete and submit this Health History EACH YEAR you participate in this ensemble, being very honest and thorough with your responses. This should not take you more than 15-20 minutes.

All information you provide in this health history will be kept in confidence and secured by Dr Bales. The information you provide will only be accessed by the band physician and shared with the band director(s), as is necessary for your best care.

We will do everything possible to accommodate any preexisting health condition to insure a healthy, exciting and educational experience.

All questions with a red * MUST be answered before you can submit this form. There are ample places in this form for you to explain any 'YES' answers and you MUST explain ALL 'YES' answers.

PLEASE, PLEASE follow the format requirements explained under the title line of each question!






Capitalize name appropriately... No all caps, please


Capitalize name appropriately... No all caps, please


Only if you have one... Capitalize name appropriately... No all caps, please


Only if you have one... Capitalize name appropriately... No all caps, please




Please select from drop down list


Please select from drop down list. If you are filing for a non-SOH ensemble enter "NONE" and proceed to next question.


What is your proposed/attained Major Degree, ex: Music Ed, Music Perf, Business, Electrical Eng, MM, DMA etc.


Please select from drop down list


If this is your first year enter "0", otherwise enter 1 or 2 or 3, etc.


Format... mm/dd/yyyy




Physical STREET address where you are living while in school


DORM Name and Room Number .. or .. Apartment Number


Of above address


Of above address... Format.... two capitalized letters please


Of above address


Format... separate more than one e-mail with a "space ; space"


Format... NNN-NNN-NNNN or enter NONE if you have not phone






Capitalize name appropriately... No all caps, please






Two capitalized letters please




Format... NNN-NNN-NNNN... separate more than one phone number with a "space ; space" or enter NONE


Format... NNN-NNN-NNNN... separate more than one phone number with a "space ; space" or enter NONE


Format... separate more than one e-mail address with a "space ; space" or enter NONE






Capitalize name appropriately... No all caps, please
Enter NONE if you have no physician



Format... NNN-NNN-NNNN
Enter NONE if you have no physician or do not know their phone number

























































































































Women should answer NO


Both Men and Women should answer either YES or NO


Men should answer NO


Men should answer NO


























If YES explain in detail below






























If YES be certain that you list them below








If YES, you might prefer to use the online form linked on the band web page "ASK DOC" for that purpose instead of explaining your concern below. That form is ONLY VIEWED/ACCESSED by the BAND PHYSICIAN. You may also catch him before, during or after rehearsals when he attends.

ALSO -- Please take time to read ALL of the medical information documents posted on the band web page!






It is quite important that you answer the questions below as completely as is possible!



Ex: Penicillin, Sulfa, Aspirin, Tylenol, Ibuprofen, Latex Materials, Peanuts, etc.

Separate multiple entries with a semicolon ";" followed by a "space". DO NOT enter each on a separate line.

If you have none, PLEASE enter "NONE"



List all medications (prescription and over-the-counter) or dietary supplements that you CURRENTLY take.

Enter drug/supplement name, dose, and frequency taken.
Separate multiple entries with a semicolon ";" followed by a "space". DO NOT enter each entry on a separate line.

Please enter NONE if you are not regularly taking any medications or dietary supplements.





Please provide your health insurance information in the fields below. It would be quite helpful to have this should you become incapacitated while on a university trip. It would also be helpful to upload a copy of the front and back of your health insurance card - this can be done below.












By selecting the APPROPRIATE statement below (either #1 or #2):

I / We acknowledge to the best of my / our knowledge, the answers to the questions on this form are complete and correct.

As a member of the SPIRIT OF HOUSTON, the student shall engage in practices, travel and performances with their ensemble. I / WE desire that the student receive the proper medical treatment/referral in the event of illness or injury while with the ensemble. I / WE consent to the administration of medical treatments, as may be deemed necessary, for emergency illness/Injury. The staff of the ensemble agrees to promptly notify the parent / guardian, if the student is a minor, in the event of any serious accident or illness.



Choose either statement 1 or 2 --- which ever applies to you




PLEASE upload a good quality photo of your face (drivers license/passport type picture). A selfie is just fine, as long as it is focused and taken with good lighting.

ALSO upload a photo of the FRONT AND BACK of your health insurance card.

If you do not have these two items available when filling this form, you may copy AND save the link below and use it later to upload these two items OR return to the band page and select the correct link to upload your photo(s).

https://goo.gl/xtG2ng













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