Health & Athletic Forms
All first-year, transfer or international students (regardless if residential or commuter) must complete the following forms:
Medical History Questionnaire (2 pages) including Immunization Record
New Patient Consent to the Use and Disclose of Health Information for Treatment Form
In addition, all new athletes must ALSO complete the following forms:
Pre-participation Physical Evaluation History Form
Pre-participation Physical Evaluation Physical Exam Form (must be signed by a DO or MD--chiropractor exam will not be accepted)
Acceptance of Risk/Medical Authorization Form
Emergency Information Form 2009-2010
All returning athletes must complete the following:
Medical History Questionnaire (2 pages - Please disregard the immunization record portion of the form if the Health Center has your record on file from your first year)
Pre-participation Physical Evaluation History Form
Pre-participation Physical Evaluation Physical Exam Form (must be signed by a DO or MD--chiropractor exam will not be accepted)
Acceptance of Risk/Medical Authorization Form
Emergency Information Form 2009-2010
Please return these forms to the Heidelberg University Health Center via fax at 419-448-2372 or mail to:
Heidelberg University
310 E. Market Street
Tiffim, OH 44883
Do not return these forms to your coach, athletic trainer or other office at Heidelberg University as these forms are reviewed by medical staff for approval prior to participation.
If you have any questions, please call Bonnie Shawberry, RN, MA at 419-448-2042 and leave a voice message or e-mail at bshawber@heidelberg.edu.