Randolph-Macon College Student Health Center P.O. Box 5005 Ashland, VA Phone:

Transcription

1 Randlph-Macn Cllege Student Health Center P.O. Bx 5005 Ashland, VA Phne: Checklist fr Students and Parents (This page is fr yu t keep) 1. Health Histry Recrds- Required fr ALL students. (athletes, residential, cmmuters, and part-time) Fall Admissin Due: August 1st Spring Admissin Due: January 31 st 2. Please mail the cmpleted Health Histry Recrd with riginal signatures t the Student Health Center at the abve address. Faxes and will NOT be accepted. If yur student is under 18 at the time f check-in please cmplete the Authrizatin t Treat a Minr frm attached. **Make and Keep a cpy f this frm fr yur persnal recrds** 3. Please print yur full name at the TOP f Pages 2 and D nt use pencil t cmplete the Health Histry Frm. 5. Students nt in cmpliance with all immunizatin requirements and TB screening fr entrance t Randlph-Macn Cllege will be referred t the Dean f Students fr Failure t Cmply with Cllege Plicy and Required frms. 6. Immunizatins: REQUIRED fr ALL students (including cmmuters): MMR (measles, mumps, rubella): 2 dses r equivalent individual dses f each Tetanus bster (within past 10 years) Pli Series Hepatitis B-- cmpleted series r signed waiver declining vaccine Meningcccal Meningitis (must have bster after 16 years f age) r signed waiver declining vaccine STRONGLY RECOMMENDED: Varicella (chickenpx) r histry f disease Hepatitis A Human Papillma Virus (Gardisil--series f 3 injectins) 7. VARSITY ATHLETES: REQUIRED: Physical Exam and sickle cell dcumentatin r waiver signed befre arriving n campus. These frms can be fund n the athletic training website 8. Health Insurance: We strngly recmmend all students have adequate health insurance cverage. Cntact yur carrier t ensure yur plicy prvides adequate cverage while living in Richmnd, VA fr services such as emergency care, lab tests, x-rays, prescriptins and preventative health visits. Students shuld pssess a cpy f the insurance card at all times. 9. First Aid Supplies: Recmmended items t bring with yu t campus: digital thermmeter, acetaminphen, ibuprfen, cld medicatins, Band-Aids, tpical antibacterial cream, a reusable cld pack, and sunscreen.

2 Student Health Center PO Bx 5005 Ashland VA Phne: (804) Fr Office Use Only: Cmpleted Needed: _HEP B Meningitis HEALTH HISTORY RECORD Mail the ORIGINAL, COMPLETED, AND SIGNED Health Histry Recrd pages directly t the Student Health Center at abve address. DUE: August 1 (Fall Admissin) January 31 (Spring Admissin) Please d nt include frms fr ther departments in yur mailing f this frm. ALL ATHLETES MUST VISIT: in additin t cmpleting this frm Faxes and will NOT be accepted Name: Date f Birth: / / Last First Middle m day year Permanent Address: Street City State /Cuntry Zip Cde Cuntry f Birth: Hme Phne: Student s Cell Phne: Preferred Name: Male Female Expected R-MC Graduatin Date: MEDICAL HISTORY (Please check all that apply and explain any "Yes" answers belw) Yes N Yes N Yes N Allergies (annual/seasnal) Eating Disrders Rheumatic Fever Anemia Gastrintestinal Prblems Tuberculsis Asthma/Exercise-Induced Asthma Gyneclgical Prblems Sexually Transmitted Diseases Bne/Jint Disrder Frequent Headaches Elevated Chlesterl Cancer Heart Disease High Bld Pressure Chicken Px Hepatitis/Liver Disease Frequent Thrat Infectins Circulatry Prblems/Bld Clts Kidney/Urinary Prblems Frequent Ear Infectins Cnvulsins/Seizures/Epilepsy Mental Health (depressin/anxiety/ther) ADD/ADHD Diabetes Mnnuclesis Other Explain Belw Current Diagnsis, Medicatins and Dsage: Allergies: medicatin/fds, etc. (include reactin) Significant illness/hspitalizatin/surgery (include dates): Histry f psychiatric/psychlgical cnditin (ex: anxiety 1/12-present) Persn t be ntified in case f emergency: Name: Relatinship: Address: Preferred Phne Number: Health Insurance Infrmatin: Insurance Cmpany Phne Number Address City State Zip Name f Plicy Hlder Individual ID ID/Grup # 1 f 4

3 Student's Full Name: PLEASE PRINT Tuberculsis Risk Assessment (TBRA) Student cmpletes upn entrance r within 6 mnths f re-entrance t the Cllege 1. Have yu ever had a psitive tuberculsis (TB) test? NO YES * If yu have had a psitive TB test in the past, yu must submit dcumentatin f the psitive test, including chest x-ray reprt and treatment recrds. Further testing may nt be required. 2. D yu have any f the fllwing signs r symptms f active TB disease? NO YES Unexplained fever/chills fr mre than 1 week Persistent cugh f unknwn etilgy fr mre than 3 weeks Cugh with bldy sputum Night sweats Unexplained weight lss Unexplained fatigue 3. D any f the fllwing situatins apply t yu? NO YES Clse cntact with a persn knwn r suspected t have TB Use f any illegal injectable drugs At risk fr Human Immundeficiency Virus (HIV) infectin Vlunteered, resided, r wrked in a healthcare facility r cngregate living setting (hmeless shelter, nursing hme, r crrectinal facility) fr lnger than 1 mnth Histry f silicsis, diabetes, renal disease, bld disrders r cancer Histry f gastrectmy, jejunilieal bypass, r chrnic malabsrptive cnditin Histry f a slid rgan transplant (kidney, heart, liver) Immunsuppressive therapy, such as prlnged crticsterid therapy, chemtherapy Or TNF-antagnist medicatins (Humira, Embrel, Remicade) Are less than 10% f nrmal bdy weight r malnurished 4. Within the past 5 years, have yu traveled t r lived in any f the fllwing areas fr mre than ne mnth? NO YES Africa, Asia, Central America, Cuba, Dminican Republic, Eastern Eurpe, Haiti, India and ther Indian subcntinent natins, Middle East (except Egypt, Saudi Arabia, Jrdan, Lebann, UAE), Prtugal, Suth America, Suth Pacific (except Australia and New Zealand). Student Signature (r guardian if under 18) : Date: If yu answered yes t any questin abve, TB testing is required. If yu have questins regarding testing fr TB please cntact the Student Health Center (804) Yur ptins fr testing are as fllws: 1. Have the test dne as sn as pssible with yur health care prvider, prir t cming t the Cllege. It may take several weeks fr the results t be sent t us, d nt delay testing. Submit a cpy f the written reprt t the Student Health Center. 2. Have the test dne at the SHC during Orientatin Week. The SHC will be pen 8:00 am until 4:00 pm Mnday - Friday. The cst f the test will be billed t yur student accunt. Test Used: Date Placed: Date Read Result: Psitive Negative CXR indicated YES NO Health Care Prvider Name: Signature Phne: 2 f 4

4 Student's Full Name: PLEASE PRINT All immunizatin dates must be verified by a health care prvider r public health fficial with full name, signature, title and cmplete address and phne number. Infrmatin must be in English Virginia State Law and Randlph-Macn Cllege Require the Fllwing Immunizatins A) MMR (Measles, Mumps, Rubella) Dse #1 / / Tw dses live vaccine required at r after 12 mnths f age, at least ne mnth apart Dse #2 / / If vaccinated separately: Measles Dse #1 / / Dse # 2 / / Mumps Dse #2 / / Dse #2 / / Rubella Dse #1 / / B) TETANUS/DIPHTHERIA/PERTUSSIS (Tdap) r TETANUS/DIPHTHERIA (TD) This bster date must be within last 10 years: / / C) MENINGOCOCCAL VACCINE (ACYW-135) This bster date must be after student turns 16: / / (r sign waiver see next page) D) HEPATITIS B VACCINE Dse #1 / / (3 dses required) Dse #2 / / Dse #3 / / (r sign waiver see next page) E) POLIO VACCINE Last Dse / / RECOMMENDED IMMUNIZATIONS a. HEPATITIS A VACCINE Dse #1 / / 2 dses vaccine given at 0, 6-12 mnths Dse #2 / / b. HUMAN PAPILLOMAVIRUS VACCINE (HPV) Dse #1 / / 3 dses at 0, 2, and 6 mnth intervals Dse #2 / / Dse #3 / / M Day Yr c. VARICELLA VACCINE *STRONGLY RECOMMENDED* Dse #1 / / Tw dses f vaccine ne mnth apart Dse #2 / / M Day Yr Or Histry f Disease / / Verified by : Health Care Prvider s Signature: Name Printed: Address: Phne: 3 f 4

5 Student's Full Name: PLEASE PRINT WAIVER DOCUMENT INFORMATION REGARDING HEPATITIS B AND MENINGOCOCCAL MENINGITS DISEASE AND IMMUNIZATION In cmpliance with Virginia state law, Randlph-Macn Cllege requires that all incming full-time students be vaccinated against meningcccal disease and Hepatitis B disease OR sign a waiver indicating they have received infrmatin abut these diseases, the availability and effectiveness f the vaccines and chse nt t be vaccinated. HEPATITIS B is a serius infectin f the liver caused by the Hepatitis B virus. The Hepatitis B virus (HBV) may cause lifelng infectin, cirrhsis f the liver, liver cancer, liver failure and death. Hepatitis B is transmitted thrugh infected bdy fluids such as bld, semen, and vaginal secretins; infectin may ccur thrugh mucus membranes and brken skin. Mst cmmnly, Hepatitis B is transmitted by sexual cntact. It may als be spread by expsure t bld thrugh cntact sprts, repeatedly sharing an infected persn s razr, tthbrush, r earrings, travel t a high-risk area, use f illicit injectable drugs r thrugh cntaminated needles use fr tatting r piercing. The Hepatitis B vaccine is safe and effective. The vaccine is generally a series f three dses given ver a perid f 6 mnths, althugh the series never has t be re-started if the schedule is interrupted. HEPATITIS B VACCINE WAIVER I have reviewed the infrmatin prvided n the risks assciated with Hepatitis B disease, and the effectiveness f any vaccine against Hepatitis B disease and I chse nt t be vaccinated at this time. Signature f student r Legal Guardian if under age 18 Date MENINGOCOCCAL DISEASE is a ptentially fatal bacterial infectin caused by the rganism Neisseria meningitis. Althugh meningcccal disease is relatively rare, the initial flu-like symptms may make diagnsis difficult. The disease may lead t brain damage, vital rgan failure, permanent disability r death. Studies indicate cllege students living in residence halls, especially freshmen residents, are at increased risk f infectin. MENINGOCOCCAL VACCINE WAIVER I have reviewed the infrmatin prvided n the risks assciated with Meningcccal disease, and the effectiveness f any vaccine against Meningcccal disease and I chse nt t be vaccinated at this time. Signature f student r Legal Guardian if under age 18 Date 4 f 4

6 AUTHORIZATION FOR CONSENT TO TREATMENT OF MINOR (I), (We), the undersigned, parent(s) r legal guardian f a minr, d hereby authrize Randlph-Macn Cllege Student Health as agent(s) fr the undersigned t cnsent t any diagnstic testing, examinatins, anesthetics medical r surgical diagnsis r treatments and/r hspital care which is deemed advisable by and is t be rendered under the general r special supervisin f any licensed medical prvider. It is understd that this authrizatin is given in advance f any specific diagnsis, treatment r hspital care being required but is given t prvide authrity and pwer n the part f ur afresaid agent(s) t give specific cnsent t any/all such diagnsis, treatment r hspital care which the afrementined medical prvider(s) in the exercise f his best judgment may deem advisable. This authrizatin shall remain effective until the Student becmes f age at 18. Date: Parent: Legal Guardian: Birthdate: Allergies t Drugs r Fds: Current Medicatins: Current Medical r Mental Health Prblems: Student s Health Care Prvider: Prvider s Phne# Father/Guardian Signature Hme Phne Business Phne Mther/Guardian Signature Hme Phne Business Phne