HEALTH HISTORY FORM. Please indicate personal emergency contact/s who MUST reside in the United States.

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1 HEALTH HISTORY FORM Student s Name: Date of Birth: Gender: Male Female M -> F F -> M Other Class: FY SO JR SR Re-admit Transfer Student ID Number: Home Address: Preferred Phone: Alternate Phone: Parent/Guardian Contact Information Name: Relationship: Address: Preferred Phone: Emergency Contact Information Please indicate personal emergency contact/s who MUST reside in the United States. Name: Relationship: Address: Preferred Phone: Insurance Information Lake Forest College REQUIRES all students to have personal health insurance. Please provide a copy of BOTH sides of insurance card. THE COPY OF YOUR INSURANCE CARD IS NOT A SUBSTITUTE FOR THE STUDENT HEALTH INSURANCE WAIVER. YOU MUST COMPLETE THE WAIVER IF YOU DO NOT WANT TO PURCHASE THE STUDENT HEALTH INSURANCE. IF THE WAIVER IS NOT COMPLETED IT WILL BE ASSUMED YOU CHOOSE TO PURCHASE STUDENT HEALTH INSURANCE AND YOU WILL BE BILLED. There are NO REFUNDS. You will find information about waiving and purchasing student health insurance at the Student Insurance page of the Health and Wellness Center website:

2 Lake Forest College Student Optional Disclosure of Private Mental Health Information Authorization Form The Illinois Student Optional Disclosure of Private Mental Health Act provides you with the opportunity to designate an adult as a contact person in the event that a College physician, clinical psychologist or qualified examiner makes a determination that you pose a clear danger to yourself or others. You are not required to designate a contact. Should you choose to designate a contact person, it can be anyone over the age of 18 (parent, friend, sibling, etc.). Please initial one of the lines below and sign and date this form. I would like to designate the following adult as a contact person in the event that I am evaluated by a mental health professional at Lake Forest College as being a clear danger to myself or to others. I also understand that I can change this designation, or decline to name a contact at any time by completing this form again. Mental Health Emergency Contact: Name: Address: Phone Number(s): Address: Relationship to Student: (home) (cell) (work) I do not want to designate a mental health emergency contact person at this time. I understand that I can change my mind at any time and designate someone by completing another authorization form. I also understand that under certain circumstances as allowed or required by law, certain College officials may contact my parents or others in the event of an emergency to protect my life or the lives of others without my express written consent. Name of Student Signature of Student College ID Number Date

3 Name: Date of Birth: Allergies Please indicate all personal allergies to medications or foods. May attach separate list if additional space is needed. Allergy to: Reaction Medications Please indicate all personal medications taken on a daily basis (include birth control, prescription, vitamins) May attach separate list if additional space is needed. Medication Taken For Dose How Often Personal Medical History Please indicate the presence or absence of a personal history of all of the following by checking yes or no. If you check yes, please indicate the approximate year in which it occurred or was diagnosed and describe below. Condition History Year Condition History Year Tobacco Use Y N Mononucleosis Y N Allergies (Seasonal) Y N Seizures Y N Asthma Y N Sickle Cell Anemia/Trait Y N Back Problems Y N Thyroid Disease Y N Sexually Bleeding/Clotting Y N Transmitted Y N Problems Infections High Blood Pressure Y N Abnormal PAP Y N Cancer Y N Meningitis Y N Diabetes Y N Liver Disease Y N Disability Y N Kidney Problems Y N Dizziness/Fainting Y N Stomach Problems Y N Eating Disorder Y N Hypoglycemia Y N Concussion Y N HIV/AIDS Y N Migraines Y N Heart Murmur Y N Heart Disease Y N Surgeries Y N Explain any yes answers or any other medical or surgical history not asked above:

4 Name: Date of Birth: Personal Psychological History Please indicate the presence or absence of a personal history of all of the following by circling yes or no. If you circle yes, please indicate the approximate year in which it occurred or was diagnosed. Condition History Year Condition History Year Anxiety Y N ADHD Y N Depression Y N Eating Disorders Y N Suicidal Thoughts Y N Bipolar Disorder Y N Suicidal Attempts Y N Substance Abuse (Illicit Drugs, Alcohol, etc.) Y N Psychiatric Hospitalizations Y N Other Y N Pertinent information of any marked psychological history: MEDICAL CONSENT FORM FOR MINORS I, (print name), am the parent/legal guardian of (print name of student), currently a minor. I authorize the Lake Forest College Student Health Center to provide medical care to the above named student, including but not limited to diagnostic examinations (including laboratory testing), administration of immunizations, and necessary medical treatment. I understand that once my child reaches the age of majority, my consent for treatment is no longer required. By signing this, I acknowledge that I have read and that I understand this consent, and that any questions I had prior to signing could be answered by calling the Student Health center at or Signature Date

5 PROOF OF IMMUNITY Illinois law (77 Ill. Adm. Code 694) and Lake Forest College policy requires: All students enrolling in more than one class must provide written evidence of their immune status with respect to certain communicable diseases (see next page), or evidence of exemption from this requirement. Proof of immunity can be supplied by Physician or other Health Care Provider completion and signature on the Lake Forest College Immunization Record or other such form. Medical Exemption A student may be exempted from one or more of the required immunizations upon acceptance by the Lake Forest Health Clinic of a written statement (see below) by a physician indicating the nature and probable duration of the medical condition or circumstances that contraindicates those immunizations, identifying the specific vaccines that could be detrimental to the student s health. Female students may be granted temporary exemption from immunization against measles, mumps, and rubella if pregnancy or suspected pregnancy is certified by a written physician s statement. If a student is on an approved schedule of receipt for any required vaccine, the student will be granted temporary medical exemption for the duration of the approved schedule. If a student s medical condition or circumstances later permit immunization, the exemption granted shall terminate and the student shall be required to obtain the immunizations from which the student has been exempted. MEDICAL EXEMPTION (PHYSICIAN S SIGNATURE REQUIRED) Student s name: should be medically exempt from the following required immunizations, as administration of these vaccines would be detrimental to this student s health: Vaccine: Condition/Circumstance: Duration: Vaccine: Condition/Circumstance: Duration: Vaccine: Condition/Circumstance: Duration: Physician signature: Date: RELIGIOUS EXEMPTION Must be based upon bona fide religious tenets and practice I, wish to be exempt from the immunization requirements noted on the Lake Forest College Immunization Record because administration of immunizing agents conflicts with my religious beliefs. Describe fully - attach additional sheets if necessary. I release Lake Forest College and their agents and employees from any responsibility for any impairment of my health resulting from this exemption. Student s Signature: Parent/Guardian Signature (if student is a minor):

6 IMMUNIZATION RECORD Name Date of Birth First Name Middle Name Last Name REQUIRED VACCINATIONS: All dates should be recorded in the mm/dd/yyyy format MEASLES, RUBELLA, MUMPS (Illinois law) MMR #1 / / (At age 12 months or later) #2 / / (At least 28 days after Dose 1) - OR - MEASLES #1 / / (At age 12 months or later) #2 / / (At least 28 days after Dose 1) RUBELLA #1 / / (At age 12 months or later) #2 / / (At least 28 days after Dose 1) MUMPS #1 / / (At age 12 months or later) #2 / / (At least 28 days after Dose 1) If unable to provide proof of immunization, may provide laboratory (serologic) evidence of immunity TETANUS, DIPHTHERIA, PERTUSSIS (Illinois law) To be compliant student must have received: 1) a primary series of 3 or more doses of any combination of Diphtheria, Tetanus, and Pertussis and, 2) one dose of Tdap received within the previous 10 years. Tetanus Toxoid is not acceptable in fulfilling this requirement. #1 / / #2 / / (at least 4 weeks after #1) #3 / / (at least 6 months after #2) Other doses received: / /, / /, / / Date of most recent Tdap booster: / / HEPATITIS B (Lake Forest College requirement) Hepatitis B, Combined Hepatitis A & B, or a positive hepatitis B surface antibody meets the requirement. Hepatitis B (Three doses of vaccine or two doses of adult vaccine in adolescents years of age) Dose #1 / / Dose #2 / / Dose #3 / / Formulation: Adult Child Formulation: Adult Child Formulation: Adult Child - OR - Combined hepatitis A and B (Three doses of vaccine) Dose #1 / / Dose #2 / / Dose #3 / / MENINGOCOCCAL CONJUGATE (Illinois law) Student must have received at least one dose of meningococcal conjugate vaccine on or after the age of 16 to meet the requirement. Date of most recent meningococcal vaccine / / MenHibrix Menactra Menveo Healthcare Provider Signature/Title Date

7 TUBERCULOSIS (TB) SCREENING QUESTIONNAIRE: PART I TO BE COMPLETED BY ALL INCOMING STUDENTS. Last Name, First Name Date of Birth Date Signature Please answer the following questions: Have you ever had close contact with persons known or suspected to have active TB disease? Yes No Were you born in one of the countries or territories listed below that have a high incidence of active TB disease? If yes, please list the country here: Afghanistan Algeria Angola Anguilla Argentina Armenia Azerbaijan 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 China, Hong Kong SAR China, Macao SAR 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 French Polynesia Gabon Gambia Georgia Ghana Greenland Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras India Indonesia Iran (Islamic Republic of) Iraq Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lesotho Liberia Libya Lithuania Madagascar Malawi Malaysia Maldives Mali Marshall Islands Mauritania Mauritius Mexico Micronesia (Federated States of) Mongolia Montenegro Morocco Mozambique Myanmar Namibia Nauru Nepal Nicaragua Niger Nigeria Northern Mariana Islands 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 Yes No Solomon Islands Somalia South Africa South Sudan Sri Lanka Sudan Suriname Swaziland Tajikistan Thailand Timor-Leste Togo Trinidad and Tobago Tunisia 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 Incidence Countries and territories with incidence rates of 20 cases per 100,000 population. For future updates, refer to Have you had frequent or prolonged visits* to one or more of the countries or territories listed above with a high prevalence of TB disease? (If yes, CHECK the countries or territories, above) Yes No Have you been a resident and/or employee of high-risk congregate settings (e.g., correctional facilities, long-term care facilities, and homeless shelters)? Yes No Have you been a volunteer or health care worker who served clients who are at increased 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 latent M. tuberculosis infection or active TB disease: medically underserved, low-income, or abusing drugs or alcohol? Yes No If the answer is YES to any of the above questions, Lake Forest College requires that you receive TB testing as soon as possible but at least prior to the start of the subsequent semester. If the answer to all of the above questions is NO, no further testing or further action is required. * The significance of the travel exposure should be discussed with a health care provider and evaluated.

8 TUBERCULOSIS CLINICAL ASSESSMENT: PART II ONLY REQUIRED IF ONE OR MORE ANSWERS TO PART I QUESTIONS WERE YES MUST BE COMPLETED BY A HEALTH CARE PROVIDER Last Name, First Name Date of Birth Date Clinicians should review and verify the information in Part I. Persons answering YES to any of the questions in Part I are candidates for either Mantoux tuberculin skin test (TST) or Interferon Gamma Release Assay (IGRA), unless a previous positive test has been documented. History of a positive TB skin test or IGRA blood test? (If yes, document below) History of BCG vaccination? (If yes, consider IGRA if possible) 1. TB Symptom Check Does the student have signs or symptoms of active pulmonary tuberculosis disease? If No, proceed to #2 or 3 If Yes, indicate presence of signs or symptoms below: Yes No Yes No Yes No Cough (especially if lasting for 3 weeks or Loss of appetite Chest pain longer) with or without sputum production Unexplained weight loss Fever Coughing up blood (hemoptysis) Night sweats Proceed with additional evaluation to exclude active tuberculosis disease including tuberculin skin testing, chest x- ray, and sputum evaluation as indicated. 2. Tuberculin Skin Test (TST) A history of BCG vaccination should not preclude tuberculin skin testing of students. (TST result should be recorded as actual millimeters (mm) of induration, transverse diameter; if no induration, write 0. The TST interpretation should be based on mm. of induration as well as risk factors.)** Date Given: Date Read: If 2 step: Date Given: Date Read: Result: mm of induration Result: mm of induration **Interpretation: Positive Negative **Interpretation: Positive Negative **Interpretation guidelines >5 mm is positive: Recent close contacts of an individual with infectious TB Persons with fibrotic changes on a prior chest x-ray consistent with past TB disease Organ transplant recipients and other immunosuppressed persons (including receiving equivalent of > 15 mg/d of prednisone for > 1 month) Persons with HIV/AIDS >10 mm is positive: Recent arrivals to the U.S. (< 5 years) from high prevalence areas or who resided in one for a significant* amount of time Injection drug users Mycobacteriology laboratory personnel History of resident, employee or volunteer in high-risk congregate settings Persons with the following clinical conditions that increase the risk of progression to TB disease: silicosis, diabetes mellitus, chronic renal failure, leukemias, lymphomas, head, neck or lung cancer, weight loss to at least 10% below ideal body weight, gastrectomy or jejunoileal bypass >15 mm is positive: Persons with no known risk factors for TB disease who, except for certain testing programs required by law or regulation would otherwise not be tested *The significance of the exposure should be discussed with a health care provider and evaluated. ** Populations defined locally as having an increased incidence of disease due to M. tuberculosis, including medically underserved, lowincome populations

9 Last Name, First Name Date of Birth Date 2. Interferon Gamma Release Assay (IGRA) Date Obtained: What method was used: QFT-G QFT-GIT T-spot Other: Result: Negative Positive Intermediate Borderline If second test performed: Date Obtained: What method was used: QFT-G QFT-GIT T-spot Other: Result: Negative Positive Intermediate Borderline 3. Chest x-ray: (Required if TST or IGRA is positive) Date of chest x-ray: If abnormal describe: Result: Normal Abnormal MANAGEMENT OF POSITIVE TST or IGRA: PART III All students with a positive TST or IGRA with no signs of active disease on chest x-ray should receive a recommendation to be treated for latent TB with appropriate medication. However, students in the following groups are at increased risk of progression from latent TB illness to TB disease and should be prioritized to begin treatment as soon as possible. Infected with HIV Recently infected with M. tuberculosis (within the past 2 years) History of untreated or inadequately treated TB disease, including persons with fibrotic changes on chest radiograph consistent with prior TB disease Receiving immunosuppressive therapy such as tumor necrosis factor-alpha (TNF) antagonists, systemic corticosteroids equivalent to/greater than 15 mg of prednisone per day, or immunosuppressive drug therapy following organ transplantation Diagnosed with silicosis, diabetes mellitus, chronic renal failure, leukemia, or cancer of the head, neck, or lung Have had a gastrectomy or jejunoileal bypass Weigh less than 90% of their ideal body weight Cigarette smokers and persons who abuse drugs and/or alcohol Student agrees to receive treatment. Treatment: Student declines treatment at this time Health Care Provider: Name: Signature: Date: Address: Phone:

10 STUDENT ATHLETE PREPARTICIPATION HISTORY FORM A Physical Examination is REQUIRED for First Year/Transfer athletes participating in intercollegiate athletics (varsity and club sports). Complete this form and take it to your healthcare provider for review prior to your physical. Student s Name: Last: First: Middle: Date: Sport: Class: FY SO JR SR Explain Yes answers below. Yes No 1. Has a doctor ever denied or restricted your participation in sports for any reason? 2. Have you ever gotten very dizzy, passed out or nearly passed out DURING exercise? 3. Have you ever gotten very dizzy, passed out or nearly passed out AFTER exercise? 4. Have you ever had discomfort, pain, or pressure in your chest during exercise? 5. Does your heart race or skip beats during exercise? 6. Has a doctor ever told you that you have: High blood pressure heart murmur High cholesterol heart infection 7. Has a doctor ever ordered a test for your heart? (for example, ECG, echocardiogram) 8. Has anyone in your family died for no apparent reason? 9. Does anyone in your family have a heart problem? 10. Has any family member or relative died of heart problems or of sudden death before age 50? 11. Does anyone in your family have Marfan syndrome, long QT syndrome, or a heart muscle problem (hypertropic or dilated cardiomyopathy)? 12. Have you ever had excessive or unexpected fatigue with exercise? 13. Do you cough, wheeze, or have difficulty breathing during or after exercise? 14. Have you ever used an inhaler or taken asthma medicine? 15. Were you born without or are you missing a kidney, an eye, a testicle, or any other organ? 16. Have you had infectious mononucleosis (mono) within the last month? 17. Do you have any rashes, pressure sores? 18. Have you had a MRSA skin infection? 19. Have you ever had a head injury/concussion? 20. Have you been hit in the head and been confused or lost your memory? 21. Have you ever had a seizure? 22. Do you have headaches with exercise? 23. Have you ever had numbness, tingling, or weakness in your arms or legs after being hit or falling 24. Have you ever been unable to move your arms or legs after being hit or falling? 25. When exercising in the heat, do you have severe muscle cramps or become ill? 26. Do you wear glasses or contact lenses? 27. Do you wear protective eyewear, such as goggles or a face shield? 28. Are you happy with your weight? 29. Are you trying to gain or lose weight? 30. Has anyone recommended you change your weight or eating habits? 31. Have you ever had an injury, like a sprain, muscle or ligament tear, or tendinitis that caused you to miss a practice or game? 32. Have you had any broken or fractured bones or dislocated joints? 33. Have you had a bone or joint injury that required x-rays, MRI, CT, surgery, injections, rehabilitation, physical therapy, a brace, a cast, or crutches? 34. Have you been told that you have or have you had an x-ray for atlantoaxial (neck) instability? 35. Do you regularly use a brace or assistive device? 36. Do you have any concerns that you would like to discuss with a medical provider? Yes No Explain Yes answers here:

11 PHYSICAL EXAMINATION FORM A Physical Examination is strongly recommended for all full-time students and part-time students living in a residence hall and is REQUIRED for First Year/Transfer athletes participating in intercollegiate athletics (varsity and club sports). Student s Name: Date: Current Medications: Past Medical/Surgical History: Last First Middle Allergies/Reaction: Date of Birth: Review of Systems: Height Weight BMI RR Pulse BP Physical evidence of Marfan Syndrome? yes no Medical Normal Abnormal Findings Appearance Eyes/ears/nose/throat Hearing Lymph nodes Heart (Auscultation): supine/sitting/standing Pulses: radial and femoral Lungs Abdomen Genitourinary (males only) Skin Musculoskeletal: I have examined this student for the following purpose(s): College residence hall Collegiate athletic participation (varsity/intramural/club sports) Study abroad This certifies that the student I have examined is medically qualified as below: Cleared without restriction Cleared, with recommendations for further evaluation or treatment for: Not cleared for: All sports Certain sports: Reason: Recommendations: Health Care Provider Name: Address: Signature: Phone: Please upload forms and enter immunization dates on the Forester Health and Wellness Patient Portal by August 1, 2017 lakeforest.medicatconnet.com