Washington & Jefferson College Report of Medical History

Transcription

1 Report of Medical History To t h e St u d e n t: Please complete this side before going to your physician for examination. The reverse side is to be completed by your physician. This information is strictly for the use of Health Services. Last Name First Name Middle Sex: M F Home Address (number & street) City State Zip Code Date of Birth Student s Cell Phone Number Student s Social Security Number Name, Relationship, and Address of Parents or Guardian Cell Phone Number Home Phone Number Student s Marital Status Family History Father Mother Brothers Sisters a g e S M Class you are entering state of h e a l t h I am adopted and don t know my family health history. o c c u p a t i o n a g e a t d e a t h cause of d e a t h y e s n o relationship Tuberculosis Diabetes Kidney Disease Heart Disease Arthritis Stomach Disease Asthma, Hay Fever Epilepsy, Convulsions Stroke High Blood Pressure Cancer (type) Pe r s o n a l Hi s t o r y Please answer all questions. Comment on all positive answers in space below or on additional sheet. Have you had? y n y n y n y n Scarlet Fever Measles German Measles Mumps Chicken Pox Malaria Gum or Tooth Trouble Sinusitis Eye Trouble Ear, Nose, Throat Trouble Meningitis Surgery Appendectomy Tonsillectomy Insomnia Frequent Anxiety Frequent Depression Recurrent Headache Recurrent Colds Head Injury with Unconsciousness Hay Fever/Asthma Tuberculosis Mononucleosis Back Problems Allergy Penicillin Sulfonamides Foods (which) High or Low Blood Pressure Rheumatic Fever or Heart Murmur Disease or Injury of Joints Tumor, Cancer, Cyst Stomach or Intestinal Trouble Gallbladder Trouble or Gallstones Eating Disorder Dizziness, Fainting Weakness, Paralysis Frequent UTI Pneumonia Stomach Intestinal trouble Ulcer IBS GERD Heart Disease Skin Disorder Kidney/Bladder Disease Anemia Epilepsy (seizure) Diabetes Thyroid Trouble Attention Deficit Disorder Alcohol or Drug problem A. Has your physical activity been restricted during the past five years? If so, give reasons and durations B. Have you received treatment or counseling for any mental health related issues? If so, give details C. Have you had any illness or injury or been hospitalized other than already noted? D. Have you consulted or been treated by clinics, physicians, or other practitioners within the past five years? (other than routine check-ups) E. Are you taking any medications? List all medicines and dosage F. Do you have any dietary problems necessitating special diets? student s signature date

2 Report of Physical Evaluation Student Name To t h e Ex a m i n i n g Physician: Please review the student s history and complete the physician s form. Please comment on all positive answers. This information is strictly for use of the Health Services. Immunizations Please list dates Month/Day/Year of Injections Required: MMR (2 dates required measles, mumps, rubella) Hepatitis B Meningococcal Meningitis (date required unless waiver signed for housing) Recommended: Tetanus (date of DT, TDAP, or DPT within past 10 years) Polio Chicken Pox Vaccine (if haven t had disease) Immunizations: Hepatitis A (2 doses) HPV (Gardasil, 3 doses, 0, 3, 6 months) Tuberculin skin test 2nd 2nd BP / Corrected Vision Right 20/ Left 20/ Height Weight 2nd 3rd 2nd 3rd 4th 5th 2nd 2nd 3rd Are there abnormalities of the following systems? Describe fully. Use additional sheet if needed. 1. Head, Ears, Nose, or Throat 2. Respiratory 3. Cardiovascular 4. Gastrointestinal 5. Hernia 6. Eyes 7. Genitourinary 8. Musculoskeletal 9. Metabolic/Endocrine 10. Neuropsychiatric 11. Skin y e s n o Is there loss or seriously impaired function of any organ? Do you have any recommendations regarding the care of this student? Please explain Is the patient now under treatment for any medical or emotional condition? Please explain Can this student engage in all usual college activities, including a standard and required Physical Education program? If no, please explain so that the required appropriate individual therapeutic and/or modified program can be arranged; and indicate what he can do as well as what he cannot do. In your opinion: Can this student participate in intramural and intercollegiate athletics? Have you any general comments? Physician s Signature Date Address: Pr i n t Physician s La s t Name Date Received at W&J Please return this form by June 6 to: W&J Gateway 60 South Lincoln Street Washington, PA 15301

3 Protecting Yourself From Meningitis In June of 2002, the Commonwealth of Pennsylvania passed Senate Bill 955, which mandates that all colleges and universities adopt meningitis vaccination policies for students living in campus housing. The legislation provides that if a student is not vaccinated for meningitis, the student must sign a waiver stating that he or she has received information from the school regarding the benefits of the immunization. Should you choose to get the vaccination as recommended, you can arrange with your health care provider to do so or elect to receive the vaccine on campus when you join W&J in the fall. Why is this vaccine particularly recommended for college students? College students, particularly freshmen living in residence halls, are at increased risk for meningococcal disease, a potentially fatal bacterial infection commonly referred to as meningitis. Students seem to be more susceptible because they live and work in close proximity to each other. Behavioral and social aspects of college life appear to be risk factors late night studying can wear down one s resistance. Late nights socializing can increase your exposure to other risk factors, such as second-hand smoke, excessive alcohol consumption, and other risks. Studies by the Centers for Disease Control and Prevention (1998) showed that freshmen students residing in residence halls are at a higher risk for contracting meningitis. The American College Health Associate, the American Academy of Pediatrics, and the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices recommend that college students learn more about meningitis and the protection afforded by the vaccine. At least 70 percent of all cases of meningococcal disease in college students are preventable by getting the vaccine. What is meningitis? Meningococcal meningitis is a rare but serious disease. When it strikes, this potentially fatal bacterial disease can lead to swelling of fluid surrounding the brain and spinal column as well as severe and permanent disabilities, such as hearing loss, brain damage, seizures, limb amputation, and even death. Ho w is it s p r e a d? Meningococcal meningitis is spread through air via respiratory secretions or through close contact with an infected person. This can include coughing, sneezing, kissing, or sharing items like eating utensils, cigarettes, and drinking glasses. What are the symptoms? Symptoms of meningitis often resemble the flu and can include high fever, severe headache, stiff neck, rash, nausea, vomiting, lethargy, and confusion. Ho w c o m m o n is it? Meningitis strikes about 3,000 Americans each year and is responsible for about 300 deaths annually. About 100 to 125 cases of meningococcal disease occur annually on college campuses, resulting in death for about 5 to 15 students per year. Can meningitis be prevented? Yes. A safe and effective vaccine is available to protect against four of the five most common strains of the disease. The vaccine provides protection for approximately three to five years. Adverse reactions to the meningitis vaccine are mild and infrequent, consisting primarily of redness and pain at the injection site, and, rarely, a fever. As with any vaccine, vaccination against meningitis may not protect 100 percent of susceptible individuals. It does not prevent viral meningitis, the form caused by a virus rather than a bacterium.

4 What can college students do to reduce their risks? Getting the vaccine is an important step to consider. A good balanced lifestyle, including a healthy diet, adequate rest, and exercise, goes a long way towards keeping you healthy in college. You should not smoke, avoid second-hand smoke, and avoid excessive use of alcohol. Tell me more about the vaccine. In the past, vaccination against meningitis was typically delayed until an outbreak had surfaced. Recent recommendations from the CDC s Advisory Committee on Immunization Practices and the American College Health Association state that the vaccination should be given before an outbreak occurs. Side effects are generally mild, as described above. The vaccine should not be administered if you are ill or running a fever, or if you are allergic to the preservative thimerosal or any other component of the vaccine. If a student is pregnant, she should consult with her private health care provider regarding the risks and benefits of the vaccine. Ho w e f f e c t i v e is t h e v a c c i n e, a n d h o w l o n g d o e s it l a s t? The vaccine has been shown to provide antibodies against meningitis in 90 percent of the population studied. Meningitis vaccine may not protect 100 percent of susceptible individuals. Protection lasts from three to five years. For more information about meningococcal meningitis Talk to your health care provider when you get your physical this summer. Visit the W&J Student Health Center, or call You might also wish to consult the Web sites of the Centers for Disease Control and Prevention (CDC), and the American College Health Association, Wh e r e c a n I g e t t h e v a c c i n e? Your private health care provider can administer the vaccine. Or, the meningitis vaccine is available in the Washington, Pennsylvania, area at MedExpress Urgent Care for $110 on a walk-in basis. For more information, contact MedExpress at

5 Acknowledgment of Meningitis Vaccine Information Student full name Home address W&J ID number Signature of parent or legal guardian, if the student is under 18 years old Please check the statement that applies to you. I received the meningitis vaccine on I will receive the meningitis vaccine prior to arrival at in September. I have read and understand the information about meningitis, and I decline the meningitis vaccine at this time. I understand that if I decide in the future that I want the vaccine, I am responsible for obtaining it. Please return this form by June 6 to: W&J Gateway 60 South Lincoln Street Washington, PA 15301