UNIVERSITY OF MOUNT UNION HEALTH RECORD

Transcription

1 UNIVERSITY OF MOUNT UNION HEALTH RECORD Name Scial Security # LAST FIRST MIDDLE ADDRESS CITY STATE ZIP CODE Date f Birth M F Cuntry f Birth Student Cell Phne Persn t Ntify in an Emergency f Abve (Relatinship) Hme Phne Wrk Phne Cell Phne CHECK EACH ITEM TUBERCULOSIS DIABETES HIGH BLOOD PRESSURE/STROKE HEART TROUBLE CANCER YES NO RELATIONSHIP FAMILY HEALTH HISTORY CHECK EACH ITEM YES NO RELATIONSHIP ASTHMA, HAY FEVER, HIVES EPILEPSY OR CONVULSIONS NERVOUS OR MENTAL DISORDER BLEEDING/CLOTTING DISORDER OTHER PERSONAL HEALTH HISTORY Have yu ever had r d yu nw have any f the fllwing (In lines f multiple statements, crss ut the inapplicable wrds.): Explain all answers belw. Yes N CHECK EACH ITEM Yes N CHECK EACH ITEM Yes BLOOD DISORDER MIGRAINE HEADACHE DIABETES TOBACCO USE HEPATITIS/ JAUNDICE DEPRESSION/ANXIETY ORTHOPEDIC PROBLEMS MUMPS SEIZURES/CONVULSIONS SURGERY HIGH BLOOD PRESSURE ALCOHOL/DRUG ABUSE HIV KIDNEY/BLADDER TUBERCULOSIS ADHD/ADD CHECK EACH ITEM ASTHMA RHEUMATIC FEVER HEART PROBLEMS SKIN PROBLEMS ALLERGIES/HAY FEVER ARTHRITIS THYROID PROBLEMS STOMACH OR BOWEL PROBLEMS If yes, r any ther medical cnditins r physical limitatins, give details N Check Each Item Yes N If yes, list: D yu take medicatin? Are yu allergic t any medicatins r latex? STATEMENT OF AUTHORIZATION Authrizatin is hereby granted, fr the health and welfare f the student, fr the Physician r Physician Assistant t admit him/her t the hspital if necessary, and t refer this student t any duly licensed physician r surgen when indicated. Permissin is given t administer any med-icatin, treatment, vaccines, etc., deemed necessary by the Health Center staff. Are yu allergic t any fds? Signature f Student Date Signature f Parent/Guardian (if student is under 18 years f age) Date 1

2 Student UNIVERSITY OF MOUNT UNION HEALTH RECORD Scial Security Number Date f Birth Please indicate what insurance cverage yu have: Student insurance Available thrugh the University f Munt Unin Private insurance thrugh a parent/spuse Please cmplete the infrmatin belw Primary Insurance: Please include cpy f insurance card- frnt and back. Name f Plicy hlder Phne DOB Relatinship f insured t student Emplyer Insurance Cmpany Insurance Cmpany Phne Member ID Secndary Insurance: Grup N. Please include cpy f insurance card- frnt and back. Name f Plicy hlder Phne Emplyer DOB Relatinship f insured t student Insurance Cmpany Insurance Cmpany Phne Member ID Grup N 2

3 Part I: Tuberculsis (TB) Screening Questinnaire (t be cmpleted by incming students) Please answer the fllwing questins: Have yu ever had clse cntact with persns knwn r suspected t have active TB disease? N Were yu brn in ne f the cuntries r territries listed belw that have a high incidence f active TB disease? (If yes, please CIRCLE the cuntry, belw) Afghanistan Algeria Angla Anguilla Argentina Armenia Azerbaijan Bangladesh Belarus Belize Benin Bhutan Blivia (Plurinatinal State f) Bsnia and Herzegvina Btswana Brazil Brunei Darussalam Bulgaria Burkina Fas Burundi Cab Verde Cambdia Camern Central African Republic Chad China China, Hng Kng SAR China, Maca SAR Clmbia Cmrs Cng Côte d'ivire Demcratic Peple's Republic f Krea Demcratic Republic f the Cng Djibuti Dminican Republic Ecuadr El Salvadr Equatrial Guinea Eritrea Ethipia Fiji Gabn Gambia Gergia Ghana Greenland Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Hnduras India Indnesia Iraq Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan La Peple's Demcratic Republic Latvia Lesth Liberia Libya Lithuania Madagascar Malawi Malaysia Maldives Mali Marshall Islands Mauritania Mauritius Mexic Micrnesia (Federated States f) Mnglia Mntenegr Mrcc Mzambique Myanmar Namibia Nauru Nepal New Calednia Nicaragua Niger Nigeria Nrthern Mariana Islands Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Prtugal Qatar Republic f Krea Republic f Mldva Rmania Russian Federatin Rwanda Sa Tme and Principe Senegal Serbia Sierra Lene Singapre Slmn Islands N Smalia Suth Africa Suth Sudan Sri Lanka Sudan Suriname Swaziland Syrian Arab Republic Tajikistan Tanzania (United Republic f) Thailand Timr-Leste Tg Tunisia Turkmenistan Tuvalu Uganda Ukraine Uruguay Uzbekistan Vanuatu Venezuela (Blivarian Republic f) Viet Nam Yemen Zambia Zimbabwe Surce: Wrld Health Organizatin Glbal Health Observatry, Tuberculsis Incidence Cuntries with incidence rates f 20 cases per 100,000 ppulatin. Fr future updates, refer t Have yu had frequent r prlnged visits* t ne r mre f the cuntries r territries listed abve with a high prevalence f TB disease? (If yes, CHECK the cuntries r territries, abve) Have yu been a resident and/r emplyee f high-risk cngregate settings (e.g., crrectinal facilities, lng-term care facilities, and hmeless shelters)? Have yu been a vlunteer r health care wrker wh served clients wh are at increased risk fr active TB disease? Have yu ever been a member f any f the fllwing grups that may have an increased incidence f latent M. tuberculsis infectin r active TB disease: medically underserved, lw-incme, r abusing drugs r alchl? N N N N If the answer is YES t any f the abve questins, the University f Munt Unin requires that yu receive TB testing as sn as pssible. If the answer t all f the abve questins is NO, n further testing r further actin is required. * The significance f the travel expsure shuld be discussed with a health care prvider and evaluated. 3

4 Part II. Clinical Assessment by Health Care Prvider Clinicians shuld review and verify the infrmatin in Part I. Persns answering YES t any f the questins in Part I are candidates fr either Mantux tuberculin skin test (TST) r Interfern Gamma Release Assay (IGRA) unless a previus psitive test has been dcumented. Histry f a psitive TB skin test r IGRA bld test? (If yes, dcument belw) Yes N Histry f BCG vaccinatin? (If yes, cnsider IGRA if pssible.) Yes N 1. TB Symptm Check Des the student have signs r symptms f active pulmnary tuberculsis disease? If N, prceed t 2 r 3 Yes N If yes, check belw: Cugh (especially if lasting fr 3 weeks r lnger) with r withut sputum prductin Cughing up bld (hemptysis) Chest pain Lss f appetite Unexplained weight lss Night sweats Fever Prceed with additinal evaluatin t exclude active tuberculsis disease including tuberculin skin testing, chest x-ray, and sputum evaluatin as indicated. 2. Tuberculin Skin Test (TST) (TST result shuld be recrded as actual millimeters (mm) f induratin, transverse diameter; if n induratin, write 0. The TST interpretatin shuld be based n mm f induratin as well as risk factrs.)** Date Given: / / Date Read: / / M D Y M D Y Result: mm f induratin **Interpretatin: psitive negative Date Given: / / Date Read: / / M D Y M D Y Result: mm f induratin **Interpretatin guidelines **Interpretatin: psitive negative >5 mm is psitive: Recent clse cntacts f an individual with infectius TB persns with fibrtic changes n a prir chest x-ray, cnsistent with past TB disease rgan transplant recipients and ther immunsuppressed persns (including receiving equivalent f >15 mg/d f prednisne fr >1 mnth.) HIV-infected persns >10 mm is psitive: recent arrivals t the U.S. (<5 years) frm high prevalence areas r wh resided in ne fr a significant* amunt f time injectin drug users mycbacterilgy labratry persnnel residents, emplyees, r vlunteers in high-risk cngregate settings persns with medical cnditins that increase the risk f prgressin t TB disease including silicsis, diabetes mellitus, chrnic renal failure, certain types f cancer (leukemias and lymphmas, cancers f the head, neck, r lung), gastrectmy r jejunileal bypass and weight lss f at least 10% belw ideal bdy weight. >15 mm is psitive: persns with n knwn risk factrs fr TB wh, except fr certain testing prgrams required by law r regulatin, wuld therwise nt be tested. 4

5 * The significance f the travel expsure shuld be discussed with a health care prvider and evaluated. 3. Interfern Gamma Release Assay (IGRA) Date Obtained: / / (specify methd) QFT-GIT T-Spt ther M D Y Result: negative psitive indeterminate brderline (T-Spt nly) Date Obtained: / / (specify methd) QFT-GIT T-Spt ther M D Y Result: negative psitive indeterminate brderline (T-Spt nly) 4. Chest x-ray: (Required if TST r IGRA is psitive) Date f chest x-ray: / / Result: nrmal abnrmal M D Y Part III. Management f Psitive TST r IGRA All students with a psitive TST r IGRA with n signs f active disease n chest x-ray shuld receive a recmmendatin t be treated fr latent TB with apprpriate medicatin. Hwever, students in the fllwing grups are at increased risk f prgressin frm LTBI t TB disease and shuld be priritized t begin treatment as sn as pssible. Infected with HIV Recently infected with M. tuberculsis (within the past 2 years) Histry f untreated r inadequately treated TB disease, including persns with fibrtic changes n chest radigraph cnsistent with prir TB disease Receiving immunsuppressive therapy such as tumr necrsis factr-alpha (TNF) antagnists, systemic crticsterids equivalent t/greater than 15 mg f prednisne per day, r immunsuppressive drug therapy fllwing rgan transplantatin Diagnsed with silicsis, diabetes mellitus, chrnic renal failure, leukemia, r cancer f the head, neck, r lung Have had a gastrectmy r jejunileal bypass Weigh less than 90% f their ideal bdy weight Cigarette smkers and persns wh abuse drugs and/r alchl Student agrees t receive treatment Student declines treatment at this time Health Care Prfessinal Signature Date 5

6 Name MANDATORY IMMUNIZATIONS REQUIRED BY THE UNIVERSITY OF MOUNT UNION A. M.M.R. (Measles, Mumps, Rubella) (Tw dses required at least 28 days apart.) Dse #1 / Dse #2 / B. Tetanus-Diphtheria-Pertussis 1. Primary series cmpleted? Yes N Date f last dse in series / 2. Date f mst recent bster dse must be within 10 years / Type f bster: Td Tdap (Preferred) Tdap bster recmmended fr ages unless cntraindicated HIGHLY RECOMMENDED IMMUNIZATIONS - (Refer t fr recmmendatins) C. Pli (Primary series, dses at least 28 days apart. Any f the three primary series are acceptable. See ACIP website fr details). 1. OPV alne (ral Sabin three dses): #1 / #2 / #3 / 2. IPV/OPV sequential: IPV #1 / IPV #2 / OPV #3 / OPV #4 / 3. IPV alne (injected Salk fur dses):.... #1 / #2 / #3 / #4 / D. Pneumcccal Plysaccharide Vaccine (One dse fr members f high-risk grups.) Date / E. Influenza (Annually) Date / F. Varicella (Birth in the U.S. befre 1980, a histry f chicken px, a psitive Varicella antibdy, r tw dses f vaccine meets the requirement.) 1. Immunizatin Dse #1 / Dse #2 / (Given at least 12 weeks after first dse ages 1-12 years and at least 4 weeks after first dse if age 13 years r lder) 2. Histry f Disease Yes N OR Birth in U.S. befre 1980 Yes N 3. Varicella antibdy / Result: Reactive Nn-reactive 6

7 Name G. Hepatitis B* (Three dses f vaccine r tw dses f adult vaccine in adlescents years f age, r a psitive hepatitis B surface antibdy meets the requirement.) 1. Immunizatin Dse #1 / Dse #2 / Dse #3 / Adult frmulatin Adult frmulatin Adult frmulatin Child frmulatin Child frmulatin Child frmulatin 2. Hepatitis B surface antibdy Date / Result: Reactive Nn-reactive H. Hepatitis A 1. Immunizatin Dse #1 / Dse #2 / I. Hepatitis A & B Cmbined Vaccine Dse #1 / Dse #2 / Dse #3 / J. Meningcccal Vaccine (At least ne dse at age 16 r greater) Quadrivalent cnjugate (preferred; administer simultaneusly with Tdap if pssible): Dse #1 / Dse #2 / Quadrivalent plysaccharide (acceptable alternative if cnjugate nt available) Meningcccal B Dse #1 / Dse #2 / K. Human Papillmavirus Vaccine (Tw dses if series started befre age 15 - three dses fr thse starting series after 15th birthday r HPV9) Date / (indicate which preparatin) Quadrivalent (HPV4) OR Bivalent (HPV2) Dse #1 / Dse #2 / Dse #3 / Infrmatin Needed fr the Office f Residence Life *In rder t cmply with an Ohi law, which went int effect July 1, 2005, any student planning n living n campus must be infrmed f the risk assciated with and the benefits f vaccinatin fr meningitis and hepatitis B. In accrdance with this law, we are prviding yu with the link t the Ohi Department f Health website ( fr further infrmatin. Please nt that this law des nt require vaccinatin, nr des it require the institutin t prvide r pay fr these vaccines. It requires nly disclsure f whether r nt yu have been vaccinated. Yur signature belw will suffice as a release fr the Health Center t be able t share the infrmatin regarding nly thse immunizatins with the Office f Residence Life, shuld the need arise. (signature and date) Immunizatin frms adapted frm the American Cllege Health Assciatin 7