ADMISSIONS PHYSICAL FORM

Transcription

1 STUDENT HEALTH CENTER Please submit by: June 15 th for fall admissions January 1 st for spring admissions ADMISSIONS PHYSICAL FM The information provided is used solely for providing health care, if necessary, while you are a student. SECTION 1 NAME DOB / / Last First MI MM DD YYYY GENDER: M F Transgender Prefer not to answer STUDENT CELL PHONE CITIZENSHIP_ ACADEMIC MAJ *COLLEGE VARSITY SPT STREET ADDRESS CITY/TOWN STATE ZIP CODE NAME OF PARENT(S)/GUARDIAN HOME PHONE: ( ) WK PHONE: ( ) CELL PHONE: ( ) HEALTH INSURANCE INFMATION NAME/ADDRESS OF SUBSCRIBER INSURANCE COMPANY NAME MEMBER ID MEMBER GROUP NUMBER Please attach copy of insurance card front and back CONSENT F MEDICAL CARE I hereby authorize and direct Westminster College to furnish a health care provider of their choice to render such medical treatment that I might need in case of illness or injury, including hospitalization and referrals where indicated. No guarantees have been made to me about the outcome of this care. I agree to be responsible for any expense in connection with the aforesaid, where my insurance policy does not provide for payment of the same. By signing below, I attest the above information provided is true and accurate to the best of my knowledge. Student Signature if over age 18 Parent/Guardian Signature if student is under age 18 RETURN: (MAIL FAX) HEALTH FMS TO: Office of Student Affairs Westminster College, New Wilmington, PA Fax: Attn: Melissa *ATTENTION: Intercollegiate athletes must complete additional forms. The athletic forms are found online at:

2 REPT OF MEDICAL HISTY To be completed by student prior to visiting your health care provider for physical examination. SECTION 2 Student name Date of birth FAMILY HISTY Age State of Occupation Age at Cause of death Have any of your relationship health death relatives ever had any _ of the following? yes _ father tuberculosis _ mother diabetes heart disease brother(s) cancer seizures psychiatric illness sister(s) kidney disease stomach disease PERSONAL HISTY HAVE YOU HAD: YES NO YES NO YES NO 1. anemia 16. ear/nose/throat trouble 31. mononucleosis 2. anxiety 17. eating disorder 32. seizure disorder 3. asthma 18. eye trouble 33. sexually transmitted infections 4. back problems 19. gum/tooth trouble 34. sickle cell disease 5. bipolar disorder 20. hay fever/allergies 35. sleep disorders/problems 6. blind/visual impairment 21. head injury w/unconsciousness 36. sports injuries 7. cancer 22. headache (recurrent) 37. suicidal thoughts/attempts 8. chicken pox 23. heart disease 38. tuberculosis 9. concussion 24. heart murmur 39. stomach or intestinal problems 10. chronic cough 25. heart palpitations 40. urinary tract infections 11 colds (recurrent) 26. hernia/rupture 41. other health problems 12. deaf/hearing impaired 27. high/low blood pressure 42. Do you smoke? 13. depression 28. impaired mobility/paralysis 43. Do you use alcohol? 14. diabetes 29. kidney disease/stones 44. Do you use drugs? 15. dizziness/fainting 30. learning disability/add/adhd Please explain all positive answers: Inpatient hospitalization or surgeries. List all medical and/or psychiatric hospitalization with dates and diagnoses: _ Current Medications and dosages Drug allergies Other allergies Student Signature Date 1. Have you ever seen a counselor/therapist? Yes No 2. Have you ever been hospitalized for a psychiatric problem? Yes No 3. Do you have a health problem that is reflected in an emotional, physical, or learning disability? Yes No 4. If yes, would you like to be contacted by one or more of the following people so that you can learn about services and accommodations: (A check mark signifies your consent to have your information sent to this person) The Campus Nurse The Campus Counselor The Director of Disability Resources

3 Student s Name Date of Birth SECTION 3: IMMUNIZATION RECD (all information must be provided in English) To be completed by health care provider. Please note: such statements as received as a child, records not available, or up to date ARE NOT ACCEPTABLE. REQUIRED IMMUNIZATIONS DATES (Month/Day/Year PENNSYLVANIA STATE REQUIREMENTS MMR #1 / / #2 / / Measles #1 / / #2 / / 2 doses of MMR (measles, mumps, and rubella). single component vaccines or positive titers. Minimum of 4 weeks between doses. Mumps #1 / / #2 / / 1 st vaccine dose cannot be given before 1 st birthday Rubella #1 / / #2 / / Positive Titer o Measles / / Attach o Mumps / / o Rubella / / Tdap Adult Tdap / / (Adacel or Boostrix) Tetanus, Diphtheria, Pertussis vaccine within the past 10 years. Tetanus/Diphtheria only vaccine is not acceptable. o Menactra / / If initial dose <16 years; booster dose at Meningitis ACWY o Menveo / / years of age. If initial dose given age = or> o Booster (if indicated) / / 16 years, no booster is needed. o Waiver Completed Meningitis Waiver All students must provide proof of immunization or sign a waiver declining the meningitis vaccine in order to be housed on campus. Hepatitis B Series #1 / / #2 / / #3 / / Series of 3 age appropriate doses (given at 0, o pediatric dose or o adult dose 1-2 mo., and 6-12 mo) at any age. Adolescents age years can be given 2 adult doses Hepatitis B Titer Hepatitis B Surface Antibody / / Attach (given at 0, and 4-6 mo) Varicella #1 / / #2 / / Series of 3 age appropriate doses (given at 0, Polio immunization, history of disease, or positive titer. Date of Disease / / 2 doses of vaccine at least 12 weeks apart if between the age of 1 and 12 years. Positive Titer Date / / Attach 2 doses of vaccine at least 4 weeks apart if o Completed Primary Series / / between the age of 13 years or older. Primary series in childhood with IPV alone. OPV alone or IPV/OPV sequentially. Health Care Provider Signature Date

4 Student s Name Date of Birth TUBERCULOSIS RISK ASSESSMENT Required for ALL Students Attending Westminster College Screening - to be completed by Health care provider only 1. Does the student have signs or symptoms of active Tuberculosis Disease? Y ( ) N ( ) * Weight loss, fever, night sweats, persistent cough for more than 3 weeks, with bloody sputum 2. Has the student ever had a positive Tuberculin Skin Test (PPD) or Quanti-FERON Tb test? Y ( ) N ( ) 3. Is the student a member of a high risk group? Y ( ) N ( ) Had close contact with anyone with active tuberculosis Use of illegal injected drugs Currently on immunosuppressive therapy Resident or employee of a nursing home, health care facility, homeless shelter or correctional facility 4. Has the student been born in, lived, traveled to, or had frequent visits (more than 4 weeks) in any of the following high risk areas: Y ( ) N ( ) Africa: all countries Asia/Southeast Asia/Asia Pacific Islands: All countries North, Central and South America: Argentina, Bahamas, Belize, Bolivia, Costa Rica, Columbia, Dominican Republic, Ecuador, El Salvador, Guatemala, Guyana, Haiti, Honduras, Mexico, Nicaragua, Panama, Paraguay, Peru, Suriname, Venezuela Europe: Belarus, Bosnia-Herzegovina, Bulgaria, Croatia, Estoria, Hungary, Latvia, Lithuania, Macedonia, Moldova, Poland, Portugal, Romania, Russian Federations, Serbia, Slovac Republic, Slovenia, Ukraine, Yugoslavia Middle East: Bahrain, Iran, Israel, Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, Syrian Arab Republic The CDC and the American College Health Association recommended that Tuberculin skin or blood testing be performed on all individuals who may be at risk for tuberculosis. If NO to all of the above questions: No further action or testing is required If Yes to any of the above questions, please do Tuberculin skin testing or the Interferon Blood test. Tuberculin Skin Test or Quanti-FERON blood test Tuberculin Skin Test Date placed Date read Result: ( )Negative mm of induration ( ) Positive mm of induration Quantiferon blood test: Date Result: Positive ( ) Negative ( ) Please attach copy of report. If positive Tuberculin skin test or Quantiferon blood test, a chest xray is required. Chest xray date: Normal ( ) Abnormal ( ). Please attach copy of report. Signature of health care provider Date

5 Student s Name Date of Birth Exam must be within past year. SECTION 4: PHYSICAL EXAMINATION Date of exam Temp Pulse BP Ht Wt NMAL ABNMAL DESCRIBE ABNMALITIES Current Medications: Head, Ears, Nose and Throat Respiratory Cardiovascular Gastrointestinal Eyes Genitourinary Musculoskeletal Metabolic/Endocrine Neuropsychiatry Skin Medication Allergies: Is this student under treatment for any physical conditions Yes o No o Cardiac Hx (murmur, palpitations, long QT syndrome, hypertension) Yes o No o Family Hx of nontraumatic sudden death before age 50? Yes o No o Family Hx of Marfan Syndrome? Yes o No o Prior Exertional Chest Pain? Yes o No o Prior Exertional Syncope? Yes o No o Prior heat stress Hx? (dehydration, heat exhaustion, heat stroke) Yes o No o Head Injury Hx (previous concussions or LOC, number and severity of episodes Yes o No o Pulmonary Hx (Asthma, EIA, etc.) Yes o No o If yes to any of the above, please explain: PARTICIPATION IN ATHLETICS This student is medically cleared to participate in intercollegiate athletics Yes o No o This student is cleared to participate in physical education courses Yes o No o List any limitations for performance Printed Name of Physician Signature of Physician Address_ Date Phone number Student Athletes I give permission to disclose the information contained in the above statement to Westminster College s Athletic Department Signature (Student)