This portion to be completed by the student Return by July 1 Please use ballpoint pen

Transcription

1 This portion to be completed by the student Return by July 1 Please use ballpoint pen Start term: Fall Exploration Spring Summer Year: Class year: Freshman Sophomore Junior Senior Transfer Full name: Preferred: Permanent Address: _ (street) (city) (state) (zip) Sex: M F Prefer Not to Answer of Birth: Parent/Guardian: Parent/Guardian: Home Phone: Home Phone: Cell Phone: Cell Phone: Emergency Contact: (if different from above) (name) (cell) (other phone) (relationship to student) Health Insurance Information Provider Name: Parent s Policy? Personal Policy? Policy Number: Group Number: (Please provide a photocopy of the front and back of insurance card) HEALTH INSURANCE IS REQUIRED FOR ALL BSC STUDENTS Current Medications Medications taken regularly: Medications taken periodically: Consent to Provide Medical Treatment I hereby authorize Birmingham-Southern College to treat all injuries and illnesses for which help is sought as deemed necessary by licensed personnel, including immunizations and medical emergencies. Student s Signature Parent/Guardian s Signature

2 Family History Has any member of your family had: Diabetes Heart Disease Hypertension Epilepsy Mental Illness Other: Personal Medical History Please provide date (month/year) of the following medical issues and note if an ongoing medical condition: Asthma Seizures Have you ever had? Bone/Joint Disease Kidney Disease Hay Fever Chicken Pox Anxiety or Depression Hepatitis Learning Disability Sleep Difficulty Anemia Rubella (German Measles) Eating Disorder Frequent Ear Infection Rubeola (Measles) Alcohol/Drug Issues Infectious Mono Mumps Dizziness/Fainting Tuberculosis Other: Attention Deficit Disorder Cancer Diabetes Severe Headaches Heart Disease Menstrual Difficulties Hypertension STDs Rheumatic Fever Hyperactivity Epilepsy Present Health Excellent Good Fair Poor of last thorough examination: Allergies/Other Issues Any medication allergy? Other allergies? Have you lost weight in the last year? Yes No If yes, how much? Do you feel any ill effects from active exercise? Yes No If yes, what? Have you ever been advised NOT to participate in athletic activity? Yes No If yes, why? List any symptoms now present or which trouble you at frequent intervals: Provide details of any illness or medical condition that requires regular treatment or lifestyle alteration: Have you received treatment or counseling for alcohol or drug abuse, eating disorder, depression, or other mental health issue? (Provide details & name of physician) Doctor s Signature The information provided on this form appears to be an accurate representation of the student s medical history. Doctor s Signature

3 This portion to be completed by the physician Return by July 1 Please use ballpoint pen Full name: of Birth: Weight: Height: Pulse: Blood Pressure: Temperature: Vision: (20/20, etc ) Right Eye: Left Eye: Physical Examination Cardiovascular: Musculoskeletal: Respiratory: Nervous: Gastrointestinal: Reproductive: Integumentary: Other: General Development: Excellent Good Fair Poor Ears: Nose: Throat: Mouth: Is there any restriction or recommendation due to chronic medical condition? Yes No If yes, give reason and extent of restriction: Immunization Record Up-to-date immunizations are required for enrollment. Must be completed and signed by your physician. MMR (Measles, Mumps, Rubella) 2 doses are required if born on or after January 1957 Dose 1 (administered at months or later) (administered at 4-6 years) DTP (Diptheria, Tetanus, Pertussis) 1) Primary series of four doses with DTap or DTP Dose 1 Dose 3 Dose 4 2) T-dap (Combined Tetanus, Diphteria, Pertussis) booster within last 5 years Polio 1) initial series completed 2) Last Booster

4 Tuberculin Skin Test If required per Tuberculosis Screening Form 1) PPD (Mantoux) within the last 12 months (tine or monovac not acceptable) Results: Negative Positive mm induration (horizontal diameter): 2) If PPD is positive, chest X-Ray required: X-Ray results: Normal Abnormal Meningococcal (Quadrivalent Conjugate Vaccine) (Booster required within last five years) Varicella History of Chicken Pox, a positive Varicella antibody, OR 2 doses of vaccine given at least 1 month apart if immunized after age 13 1) History of Chicken Pox? Yes No 2) Immunization: Dose 1 3) Varicella Antibody Results Reactive Non-reactive Recommended Immunizations Hepatitis B (in 3 doses) or Postive Hepatitis Surface Antibody (recommended for Pre-Health, Pre-Med students) 1) Dose 1 2) Hepatitis B Surface Antibody Results Reactive Non-reactive Dose 3 Physician s Signature Physician s Name (Print please) Phone Number Physician s Address *INTERNATIONAL STUDENTS MUST PROVIDE ENGLISH TRANSLATION* Return all copies to Birmingham-Southern College, Health Services, Box , Birmingham, AL, 35254

5 Tuberculosis (TB) Screening Questionnaire Full name: Please answer the following: of Birth: Have you ever had close contact with someone known of suspected to have active TB disease? Yes No Were you born in one of the countries listed below that have a high incidence of active TB disease? Yes No (If yes, please circle the country below) Afghanistan Algeria Angola Argentina Armenia Azerbaijan Bahrain Bangladesh Belarus Belize Benin Bhutan Bolivia (Plurinational State of) Bosnia and Herzegovina Botswana Brazil Brunei Darussalam Bulgaria Burkina Faso Burundi Cabo Verde Cambodia Cameroon Central African Republic Chad China Colombia Comoros Congo Côte d Ivoire Democratic People s Republic of Korea Democratic Republic of the Congo Djibouti Dominican Republic Ecuador El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Gabon Gambia Georgia Ghana Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras India Indonesia Iran (Islamic Republic of) Iraq Kazakhstan Kenya Kiribati Kuwait Kyrgyzsran Lao People s Democratic Republic Latvia Lesotho Liberia Libya Lithuania Madagascar Malawi Malaysia Maldives Mali Marshall Islands Mauritania Mexico Micronesia (Federal States of) Mongolia Morocco Mozambique Myanmar Namibia Nauru Nepal Nicaragua Niger Nigeria Niue Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Republic of Korea Republic of Moldova Romania Russian Federation Rwanda Saint Vincent and the Grenadines Sao Tome and Principe Senegal Serbia Seychelles Sierra Leone Singapore Solomon Islands Somalia South Africa South Sudan Sri Lanka Sudan Suriname Swaziland Tajikistan Thailand Timor-Leste Togo Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Republic of Tanzania Uruguay Uzbekistan Vanuatu Venezuela (Bolivarian Republic of) Viet Nam Yemen Zambia Zimbabwe Source: World Health Organization Global Health Observatory, Tuberculosis Countries with an incident rate of 20 cases per 100,000 population. For future updates, refer to Have you had frequent or prolonged visits to one of more of the countries listed above with a high Yes No prevalence of TB disease? (If yes, please check the countries above) Have you been a resident and/or employee of high-risk congregate settings (e.g., correctional facilities, Yes No long-term care facilities, and homeless shelters)? Have you been a volunteer or health-care worker who served clients who are at risk for active TB disease? Yes No Have you ever been a member of any of the following groups that may have an increased incidence of Yes No latent M. tuberculosis infection or active TB disease medically underserved, low-income, or abusing drugs or alcohol? If the answer is YES to any of the above questions, Birmingham-Southern College requires that you receive TB testing as a part of your medical exam. If all answers are NO, no further testing/action is required. *The significance of the travel exposure should be discussed with a health care provider and evaluated.