Holy Family University, Student Health Services, Directions for Completion of Health Packet

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1 1 Holy Family University, Student Health Services, Directions for Completion of Health Packet All forms are to be returned to Health Services by August 1, for the Fall Semester Every full-time undergraduate student admitted to Holy Family University is required to complete the Health Packet provided by Health Services. The packet contains a Demographic Form and a Health History Form to be completed by the student. It also includes a Physical Form and an Immunization Form to be completed by the student s Health Care Provider (HCP). The Immunization Form contains the Meningitis Response Form that needs to be completed by students who will be living in University Housing. The Health Packet Forms Include: Demographic Sheet: Page 3 To be completed by the student. The consent for treatment must be signed by a parent or guardian if the student is 17 or younger when school begins. Health History Form: Page 4 This form is to be completed by the student. Physical Examination Form: Page 5 This form must be completed and signed by your HCP (DO, MD, NP, PA). Students whose annual physical is in August may submit their physical from the previous August. Transfer students who are not on an athletic team can submit a copy of their original college entrance physical. Transfer students who are on an athletic team will need to have a physical completed yearly. Required Meningitis Response Form for Students Living in University Housing: Page 6 PA Law #955 requires students living in university housing to receive the meningitis vaccine or to sign a waiver of refusal. Students who fail to complete this form and are not immunized against meningitis will not be allowed to move into housing until this form is completed or student submits proof of immunization to meningitis. The Meningitis Response Form is located on the top of page 6. Immunization Form: Page 6 This form is located on the bottom half of page 6. Your HCP must complete and sign the immunization form or send an official copy of the student s current immunization record. Athletic Requirement: All athletes are required to have a complete physical on file. The student s HCP needs to complete the physical on the enclosed form and check the applicable response regarding athletic participation. A letter of explanation will need to be sent by the HCP for any athlete who is not cleared for unrestricted athletic participation. The letter should include an estimated timeframe for when the student can fully participate in her/his sport. For questions contact Maureen Niche CRNP: at: or , fax or mail forms to Health Services. Fax: Mail: Health Services, Holy Family University, 9801 Frankford Ave, Philadelphia, PA, 19114

2 2 Meningococcal Disease Information Information for College Students and their Parents What is meningococcal disease? Meningococcal disease is a severe bacterial infection of the bloodstream or meninges (a thin lining covering the brain and spinal cord). Who gets meningococcal disease? Anyone can get meningococcal disease, but it is more common in infants and children. For some college students, such as freshmen living in dormitories, there is an increased risk of meningococcal disease. Between 100 and 125 cases of meningococcal disease occur on college campuses every year in the United States; between 5 and 15 college students die each year as result of infection. Other persons at increased risk include household contacts of a person known to have had this disease, and people traveling to parts of the world where meningitis is prevalent. How is the germ meningococcal spread? The meningococcal germ is spread by direct close contact with nose or throat discharges of an infected person. Many people carry this particular germ in their nose and throat without any signs of illness, while others may develop serious symptoms. What are the symptoms? High fever, headache, vomiting, stiff neck and a rash are symptoms of meningococcal disease. Among people who develop meningococcal disease, 10-15% dies, in spite of treatment with antibiotics. Of those who live, permanent brain damage, hearing loss, kidney failure, loss of arms or legs or chronic nervous system problems can occur. How soon do the symptoms appear? The symptoms may appear two to 10 days after exposure, but usually within five days. What is the treatment for meningococcal disease? Antibiotics, such as penicillin G or ceftriaxone, can be used to treat people with meningococcal disease. Is there a vaccine to prevent meningococcal meningitis? Yes, a safe and effective vaccine is available. The vaccine is 85% to 100% effective in preventing four kinds of bacteria (serogroups A, C, Y, W-135) that cause about 70% of the disease in the United States. The vaccine is safe, with mild and infrequent side effects, such as redness and pain at the injection site lasting up to 2 days. After vaccination, immunity develops within 7 to 10 days and remains effective for approximately 3 to 5 years. As with any vaccine, vaccination against meningitis may not protect 100% of all susceptible individuals. How do I get more information about meningococcal disease and vaccination? Contact your family physician or your student health service. Additional information is also available on the Centers for Disease Control and Prevention website: and the American College Health Association website:

3 3 PLEASE CHECK ONE: Fall Semester Year Spring Semester Year Mandatory Health History Form, Physical, and Immunizations for Full-Time Undergraduate Students Forms Due: Fall Semester: August 1st Spring Semester: January 1 st CHECK ALL THAT APPLY Freshman Transfer Athlete Sport Residential Student Commuter Student ID #: Birth Date (MM-DD-YY): Last Name: First Name: MI: Address (Street): City: State: Zip Code: Phone: Address: Cell Phone: Sex: Male Female Citizenship: U.S. Other: EMERGENCY CONTACT Name: Last Name First Name Relationship: Address: City: State: Country: Zip Code: Cell Phone Number: Business Telephone Number: Home Telephone Number: Address: HEALTH INSURANCE INFORMATION Name of Insurance Co.: Policy #: Subscriber s Name: AUTHORIZATION TO PROVIDE MEDICAL CARE I hereby authorize the Holy Family University Health Services to provide medical and minor surgical care to (student name) on his/her request and to arrange for such care as necessary in the event of emergencies. Student Signature (if 18 years or older) Parent/Guardian Signature (if student is under 18 years) Information on this form is confidential, it is for the Health Services use only; it will not be released without the student s written consent, and it will not affect admission status. this form to or Fax , or mail to Holy Family University, Health Services, 9801 Frankford Ave, Philadelphia, PA 19114

4 4 HOLY FAMILY UNIVERSITY: HEALTH HISTORY FORM Student Name: Date of Birth: Student ID Number: Form Due: Fall Semester: August 1 st and for Spring Semester: January 1 st Do you have any drug allergies? Specify: Do you have any allergies to insect stings, foods, latex, or others? Specify: Do you have any family history of medically unexplained or cardiac-caused sudden death under the age of 50? Please explain. Do you have asthma? Please list medications and dosage you are taking for this condition. Do you have diabetes? Please list medications and dosage you are taking for this condition. Do you have hypoglycemia (low blood sugar)? Do you have any loss or impaired function of your eyes, ears, kidneys,lungs,ovaries,testicles? Have you had a previous concussions or loss of consciousness? Please explain Have you ever fainted (syncope) or had near syncope with exercise? Have you ever had symptoms of exercised-induced bronchospasm, i.e. asthma, allergy Have you ever had an incident of heart-related illness? Please explain. Have you had any operations? Please list. Have you had any serious illnesses in the past? Please explain. Have you been hospitalized in the past five years? Please explain. Are you currently being treated for any chronic/prolonged condition? Please explain. Do you have anxiety or depression? Please explain. Please list all other medications that you are currently taking and their dosages Student Signature: Date: Note to Athletes: Your signature above authorizes the release of this information between Health Services and the Athletic Training staff at Holy Family University. , fax or mail forms to: Fax: (215) , Mail: Holy Family University, Health Services, 9801 Frankford Ave, Philadelphia, PA, 19114

5 5

6 _ Required Form 6 Holy Family University Immunization Form Form Due: August 1 for Fall Semester or January 1 for Spring Semester this form to or Fax to (215) ; or mail to: Health Services, Holy Family University, 9801 Frankford Ave, Philadelphia, PA, Student Name: Date of Birth: Student ID#: Required Meningitis Response Form for Students Living in University Housing Residential Students Required Response Form: PA Law 955 requires students living in university housing to receive the meningitis vaccine or to sign a waiver of refusal. Students who fail to complete this form will not be allowed to move into housing until this form is completed or student submits proof of immunization to meningitis. STUDENT: Check one box only: I have had the meningococcal meningitis immunization within the past 10 years. Date received: I have read, or have had explained to me, the information regarding meningococcal meningitis disease. I understand the risks of not receiving the vaccine. I have decided that I (my child) will not obtain immunization against meningococcal meningitis disease. Signed: Date: Student Signature (or Parent/Guardian Signature if student under 18 years) HEALTH CARE PROVIDER: Complete this Section OR send a Copy of the Student s Current Immunization Record. Please list vaccine dates for the following: Tuberculin Skin test (PPD): Date given Date read Results MMR: Date: Dose 1 Dose 2 Titer Result DPT series completed Date: TDAP/Adacel (Circle) Booster Date OPV series completed Date: Meningitis: Menactra/Menveo (Circle One): Date: Dose 1 Dose 2 Hepatitis B: D a t e : Dose 1 Dose 2 Dose 3 Titer Varicella Date: Dose 1 Dose 2 Disease HPV2/HPV4 (Circle one) Date: Dose 1 Dose 2 Dose 3 Influenza: Date ******************************************************************************************************************* I certify that the above is complete and accurate. Provider Name: MD, NP, PA Print or Stamp Signature Address: City/State/Zip: Phone: Fax: Date form completed:

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