Dear Incoming Student:

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Alfred Carson
6 years ago
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1 Dear Incoming Student: As the Director of Wellness Services, I want to welcome you to Nyack College! Our Staff is dedicated to providing you with quality health care. Our philosophy is based on the wellness of each student, and our goal is to provide care for each student s spirit, mind and body. Both the Office of Counseling Services and the Office of Health Services are located in Boon Campus Center. Because the State of New York requires that all students document their MMR immunizations and respond to the Meningitis immunization choices prior to being enrolled at a college or university, a link to the NY State Required Immunizations form has already been sent to you by the Admissions Office your signed form must be returned to the Admissions Office in order for you to become enrolled at Nyack College. However, there is certainly great benefit to our offices in obtaining additional health information on each student. In order that we would be able to serve you most effectively, we also request that each incoming student submit the following information: Personal Health Report Form (2 single-sided pages) Physical Examination Form General Immunization Form Please complete and sign the Personal Health Report Form. Then take both the Physical Examination Form and General Immunization Form (to show us what additional immunizations you have had besides the MMR and possibly the Meningitis immunizations) to your physician for completion. If you have already had a physical examination within the past year, you need only include a copy of that report. This will enable our offices to have accurate information regarding your current health status. At your earliest convenience, please return all completed forms to: Health Services Nyack College 1 South Blvd. Nyack, NY If you will be covered by your family s health insurance while attending Nyack College, please be sure to fill in your policy number and the name of the insurance company. This information will aid our offices in serving you and referring you to area physicians who are part of your health care network. YOU NEED TO KNOW YOUR FAMILY S HEALTH INSURANCE INFORMATION BEFORE COMING TO SCHOOL. If you have no other insurance coverage, while you attend Nyack College you will have as your primary coverage the Student Accident and Health Insurance Plan that is mandatory for all full-time students (this insurance becomes secondary coverage for those students covered by their family s plan). We look forward to serving your basic health care needs as you begin your college experience at Nyack. Since the offices of Counseling Services and Health Services are not staffed during the summer, direct any questions to the Student Development Office at Sincerely, Drusila Nieves Director of Wellness Services

2 NYACK COLLEGE DEPARTMENT OF HEALTH SERVICES PERSONAL HEALTH REPORT FORM Please answer all questions & keep a copy of these pages for your record. This information is strictly CONFIDENTIAL and will be used as an aid to provide necessary health care while you are a student. Information supplied will become a part of your health record, will not influence your standing at the College and will not be released to anyone except by your written authorization. RETURN COMPLETED FORM TO: HEALTH SERVICES, NYACK COLLEGE, 1 SOUTH BLVD., NYACK, NY NAME: Last: First: Middle: Maiden: DATE OF BIRTH: SOC. SEC. NO: AGE: HOME ADDRESS: PARENT/ LEGAL GUARDIAN Parent/ Guardian # (Work) Student Phone # (cell) (home) LOCAL ADDRESS NOTIFY IN CASE OF EMERGENCY: RELATIONSHIP: ADDRESS: CITIZEN USA: yes or no (circle one) CLASS: Freshman Sophomore Junior Senior SEX: M F MARITAL STATUS: INSURANCE INFORMATION: (Please staple copy of both sides of insurance card to this form) NAME OF INSURANCE: INS. PHONE NO: SUBSCRIBER S NAME: POLICY NO: GROUP NO: PRIMARY PHYSICIAN: OFC. PHONE #: FAX #: ADDRESS: PERSONAL HISTORY: Please comment on all yes answers in comment section or on an additional sheet. Have you had? YES NO YES NO YES NO ALLERGIES, SEASONAL HIGH BLOOD PRESSURE SCARLET FEVER ARTHRITIS JAUNDICE SEIZURE DISORDERS ANOREXIA/BULIMIA MALARIA SMALL POX ASTHMA MENTAL ILLNESS STOMACH ULCERS CANCER MIGRAINE HEADACHES STREP THROAT CHICKEN POX MONONUCLEOSIS TONSILLITIS DIABETES MUMPS SUICIDAL TENDENCIES DIPHTHERIA NERVOUS BREAKDOWN THYROID DISORDER DYSMENORRHEA PNEUMONIA TUBERCULOSIS EMOTIONAL ILLNESS POLIOMYELITIS TYPHOID FEVER FREQUENT COLDS RHEUMATIC FEVER WHOOPING COUGH HEART DISEASE RUBELLA/GER MEASLES WEIGHT GAIN/ LOSS HEPATITIS RUBELLA/REG MEASLES SURGERY

3 NYACK COLLEGE DEPARTMENT OF HEALTH SERVICES PERSONAL HEALTH REPORT FORM (con t) HOSPITALIZATIONS: Reason Date LIST ALLERGIES TO DRUGS, FOODS, POLLEN, MOLDS, OTHER: LIST MEDICATIONS TAKEN REGULARLY: COMMENTS LIST ANY ILLNESS OR INJURY OTHER THAN ALREADY NOTED FAMILY HISTORY DISEASE ALLERGY CANCER DIABETES EPILEPSY YES NO RELATIONSHIP DISEASE YES NO RELATIONSHIP HEART DISEASE KIDNEY DISEASE NERVOUS DISORDERS TUBERCULOSIS By signing this, I affirm that all information in this document is correct and complete. I also agree to inform the Health Services Office of any changes in my health or in the information on this form. I hereby authorize the release of my medical records (health history, physical exam, immunizations, etc) to the Athletics Staff, ATS or any Nyack College Campus, if needed. All records/ medical information will be kept confidential. Student s Signature Date Parent s Signature (in addition to student s, if student is a minor)

4 Physical examination must be within one year of entrance date. PLEASE LIST DRUG ALLERGIES HEALTH SERVICES PHYSICAL EXAMINATION TO BE COMPLETED BY M.D./ N.P. Name (Last, First, MI): Date of Examination: Sex: Age: Date of Birth: Blood Pressure: Pulse Rate: Height: Weight: Contact Lenses: yes no Vision: Corrected R 20/ Glasses: yes no Uncorrected L 20/ REVIEW OF SYSTEMS: Please note any abnormalities or history of past medical illness or chronic disease, along with current status. CLINICAL EVALUATION: Check each item in proper column. Enter NE if not evaluated. NORMAL ABNORMAL NOTE: Give details for each abnormality with corresponding item number. 1. Head, Neck, Face and Scalp 2. Nose and Sinuses 3. Mouth and Throat 4. Teeth and Gingiva 5. Ears 6. Eyes 7. Lungs, Chest and Breasts 8. Heart 9. Vascular System 10. Abdomen and Viscera 11. Ano-rectal 12. Endocrine System 13. G-U System 14. Upper Extremities 15. Feet 16. Lower Extremities 17. Spine, other Musculo-Skeletal 18. Skin and Lymphatic 19. Neurologic 20. Psychiatric 21. Is there loss or seriously impaired function of any paired organ? Yes No Do you have any general comments? PHYSICIAN NAME: SIGNATURE: DATE OF EXAMINATION: PHYSICIAN TELEPHONE: ADDRESS: FAX #:

5 HEALTH SERVICES/ GENERAL IMMUNIZATION RECORD Because the State of New York requires that all students document their MMR immunizations and respond to the Meningitis immunization choices prior to being enrolled at a college or university, a link to the NY State Required Immunizations form has already been sent to you by the Admissions Office your signed form must be returned to the Admissions Office in order for you to become enrolled at Nyack College. We request that your physician list below any additional immunizations that you have received: NAME: DOB: / / SOCIAL SECURITY # A. TETANUS- DIPHTHERIA DATE 1. Primary series of four doses with DtaP or DTP #1 / / #2 / / #3 / / last booster #4 / / 2. Received tetanus-diphtheria booster within the last ten years. / / B. TUBERCULOSIS - Check appropriate box. 1. PPD (Mantoux) or Tine test within the past year. / / Test Results: Positive Negative 2. Positive PPD or Tine - Chest x-ray required. / / X-Ray Results: Positive Negative 3. Had BCG vaccine - Chest X-ray required if PPD not done. / / X-Ray Results: Positive Negative C. POLIO 1. Completed primary series of polio immunizations : Yes No / / D. HEPATITIS B (3 doses of vaccine or a positive Hepatitis surface antibody meets the requirement) 1. Dose 1 -. / / 2. Dose 2 - / / 3. Dose 2 - / / E. HEPATITIS A 1. Dose 1 - / / 2. Dose 2 - / / F. HPV (Human Papillomavirus) / / PHYSICIAN NAME: DATE OF EXAMINATION: SIGNATURE: PHYSICIAN TELEPHONE:

Part I: Health Form. This form is to be completed by the incoming student by July 15. Name: Date of Birth:

Part I: Health Form. This form is to be completed by the incoming student by July 15. Name: Date of Birth: Part I: Health Form This form is to be completed by the incoming student by July 15. Name: Date of Birth: Last First Middle MM/DD/YYYY Social Security #: Marital Status: ( ) Single ( ) Married ( ) Divorced