Dear Roanoke College Student:

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1 Dear Roanoke College Student: Congratulations on your acceptance and decision to attend Roanoke College. We at Health Services look forward to serving your needs and wish you the best of luck as you begin your education. Every new full time, or transfer student entering the college is REQUIRED to properly complete and return this health record. The tuberculosis risk assessment and if indicated the tuberculin skin test (PPD) must be within twelve months prior to entrance to Roanoke College. The physical must be within twelve months prior to entrance to Roanoke College. Please carefully read the list of required immunizations to be sure that you have complied fully with state and college requirements. Commonwealth of Virginia Law (Code of Virginia, Section ) requires that all full time students submit an immunization history that has been signed by a health care provider who documents all required immunizations. FAILURE TO RECEIVE ALL THE REQUIRED IMMUNIZATIONS AND TO PROVIDE DOCUMENTATION WILL BLOCK YOU FROM FINAL REGISTRATION FOR CLASSES. In addition to the required immunizations, there are two recommended vaccines: Varicella (chickenpox) if you have not had the disease and Gardasil, a vaccine for girls and women age 9 26 which offers protection against diseases caused by the human papilloma virus (HPV). Students are exempt from the immunization requirements if a medical contraindication or religious belief prohibits immunization. A signed statement from a health care provider is required for exemption. This form is available on our website. Those born before 1957 are also exempt from the requirement for measles/mumps/rubella (MMR) vaccine. Many services are provided to students at no cost. Expenses incurred for prescription medication, physicals, immunizations, allergy injections, in house laboratory procedures, or off campus doctor visits, x rays, laboratory procedures, emergency room visits, or hospitalizations are the student s responsibility. Parents and students are encouraged to review health insurance prior to arrival to ensure the policy provides adequate coverage while living in Salem, VA. A student without insurance should visit our website at to review the plan available to Roanoke College students. *International students are required to have health insurance. Please review the health insurance requirements letter located on MyRC or Health records should be returned to: Roanoke College Health Services, 221 College Lane, Salem, VA If you have any questions please contact us at (540) , FAX (540) or e mail HEALTH FORMS MUST BE RETURNED AT LEAST ONE MONTH PRIOR TO THE START OF THE SEMESTER. FINAL REGISTRATION FOR CLASSES WILL BE BLOCKED UNTIL HEALTH FORMS ARE COMPLETED. FOR OFFICE USE ONLY ROANOKE COLLEGE Staple photo here HR Complete HEALTH SERVICES write student name

2 HR Incomplete 221 COLLEGE LANE on back Pg 1 Td MMR SALEM, VA Polio Hep B PHONE (540) Meng PPD Pe FAX (540) Sports Clearance Yes No Drug Allergies Roanoke College Health Record Release of Information When appropriate to ensure your health, well being and academic success, the Health Center may, in particular circumstances, share some of the information on your health record with the appropriate college official, only if deemed necessary. Freshmen and/or transfer students who will be participating in athletics will have some of the health information released to the Athletic Department. It will be your responsibility to inform us if you do not wish to release any specific information. I HAVE READ AND UNDERSTAND THE ABOVE STATEMENT. Student Signature Date College entrance year Fall or Spring Freshman Transfer Name Last First Middle Roanoke College I.D# Date of Birth Country of Birth Gender: Male Female Home Address Street City State Zip Code Telephone # ( ) Student cell phone # ( ) RC Parent/Guardian Name(s) Work /Cell phone # Work/Cell phone # In Case of Emergency Notify Name and relationship to student Telephone# including area code Family Physician Name Phone # Address Attach a front and back copy of your health insurance card, and a copy of your prescription card if separate, to this form. Whenever visiting Student Health or other care provider, have your insurance card(s) with you. Name of Medical Insurance Subscriber s Name Policy Number Group Number MEDICAL HISTORY (CONFIDENTIAL) HAVE YOU EVER HAD ANY OF THE FOLLOWING? Check all that apply and give details below: Arthritis Weight loss /gain >10lbs. Anorexia/bulimia Allergies (annual/seasonal) Mononucleosis Hepatitis Athletic or joint injuries Frequent throat infections Orthopedic problems Asthma/ exercise induced Head Injury/concussion Chest pain with exercise Asthma Irritable bowel/spastic colon Fainted while exercising Cancer/Hodgkin s Recurrent bladder/kidney Unexplained shortness of breath Frequent colds/bronchitis infection or fatigue with exercise Chronic indigestion/ulcers Anxiety/depression Premature death (<50) in Frequent ear/sinus infections Substance abuse immediate family due to heart Diabetes Epilepsy/seizure disorder disease Dizzy or fainting spells Sexual assault/abuse Family history of Marfan s High blood pressure Anemia/bleeding trait syndrome, or any other Chronic headaches/migraines Menstrual problems genetically inherited syndrome. Heart murmur/ Chicken pox Other explain below palpitations/enlargement Breast lumps Remarks or Additional information Student name 1 RC I.D. #

3 Allergies: medication/foods, etc. (include reaction) Previous significant illness/hospitalization/surgery (include dates): Previous history of psychiatric/psychological condition (include dates): Medications: List all medications taken on a regular or frequent basis. (Include vitamins, birth control pills, and over the counter medications). Name Dosage Name Dosage Name Dosage Name Dosage If you are currently prescribed medication for ADD/ADHD or receive allergy injections, a letter from your physician with documentation of diagnosis and medication dosage are required and must be dated within twelve months. REQUIRED IMMUNIZATIONS *MUST BE REVIEWED AND RECORDED BY A HEALTHCARE PROVIDER TETANUS BOOSTER/TDAP PREFFERED (WITHIN THE LAST TEN YEARS) DATE M.M.R. (Measles, Mumps, Rubella) Two doses required after 12 months of age: Date #1 # 2 OR ATTACH COPY OF TITER RESULTS POLIO (COMPLETED) YES NO HEPATITIS B Series of 3doses #1 #2 #3 or sign waiver if decision made NOT to receive vaccines. Hepatitis B Waiver I have read the information about Hepatitis B and the Hepatitis B vaccine. I understand the risks of the disease, however, I choose not to receive the vaccine. (Student Signature (parent/legal representative if under age 18) MENINGOCOCCAL Vaccine Date or waiver must be signed if decision made NOT to receive vaccine. Meningococcal Vaccine Waiver I have read the information about meningococcal meningitis and understand the risk of the disease. However, I choose not to receive the vaccine. I understand that in the event of an outbreak, unvaccinated students will be at increased risk for contracting the illness. (Student Signature (parent/legal representative if under age 18) RECOMMENDED IMMUNIZATIONS VARICELLA (Chicken Pox) #1 #2(if applicable) GARDASIL (HPV) #1 #2 #3 List any other Immunizations and dates: (ex: any not listed above, or given for travel) TUBERCULOSIS SCREENING (see next page to assess risk status) Students who have received the BCG Vaccine are NOT exempt from TB screening. An intradermal PPD is required, NOT a TINE TEST, AND MUST BE WITHIN 12 MONTHS PRIOR TO ENTRANCE TO Roanoke College. ANY POSITIVE PPD PAST OR PRESENT REQUIRES A CURRENT CHEST XRAY WHICH MUST BE DONE WITHIN 12 MONTHS PRIOR TO ENTRANCE TO ROANOKE COLLEGE. (Attach a written copy of the x ray report). 1. At risk for TB exposure Date TB skin test placed Date read Interpretation Positive Negative Induration mm (if none, write 0 ) (if positive, copy of CXR result, required) 2. History of prior positive TB skin test Date positive Date of Chest X ray (copy of results must accompany this form) Medication(s) Yes No If yes, Drug Name(s) Treatment dates 3. Not at risk for TB exposure No skin test placed Student name RC I.D. # 2

4 Tuberculosis Risk Assessment The US Public Health Service and the Centers for Disease Control recommend that tuberculosis (TB) skin testing (Mantoux PPD) be performed on all individuals who may be at increased risk of tuberculosis disease. If any of the following statements are applicable to you, you are required to have the tuberculosis skin testing. Unexplained weight loss Unexplained night sweats Unexplained persistent cough for more than three weeks Cough with the production of blood sputum Close contact with a known case of active tuberculosis Use of illegal injected drugs HIV infection If you were born in or have traveled within the past 5 years to countries where TB is prevalent. Worked in a health care setting, Cancer Diabetes Kidney Disease Immunosuppressive therapy Removal of part of your stomach Silicosis The following areas have been identified to have a higher incidence of TB: Afghanistan Ethiopia Bangladesh India Brazil Indonesia Cambodia Kenya China Latin America Congo Mozambique Myanmar Nigeria Pakistan Philippines Russian Federation South Africa Thailand Uganda Tanzania Viet Nam Zimbabwe Physical Health Evaluation Exam within 12 months prior to entering Roanoke College TO THE EXAMINING PROVIDER: Please review the student s history and complete this physical form. Comment on all abnormal findings. This student has been accepted. The information supplied will be only as a background for providing health and mental health care, if this is necessary. This information is strictly confidential. Temperature Pulse Blood Pressure Height (inches) Weight (lbs) Hemoglobin or Hematocrit Urinalysis: Glucose Protein Blood Corrected Vision: Right 20/ Left 20/ Hearing: Right Left Normal Abnormal Normal Abnormal Skin Lungs Lymph Heart Supine Standing Eyes Abdomen Ears Back/Spine Nose Genitalia Mouth/Throat Extremities Neck/Thyroid Neurological Breasts Femoral pulses RECOMMENDATIONS FOR PHYSICAL ACTIVITY: PE, intramurals, and intercollegiate sports *Limited *If limited please explain: Unlimited Is the patient now under treatment for any medical or emotional conditions? Yes No Does the student take any medications regularly? Yes No Do you have any recommendations regarding the care of this student? Yes No Comments Health Care Provider s Signature Date Print Health Care Provider s Name, Office Address, Phone & Fax # Return completed health records to: Roanoke College Health Services, 221 College Lane, Salem, VA Contact information: Phone (540) Fax (540)

5 MENINGOCOCCAL AND HEPATITIS B DISEASE RISKS AND VACCINATION The Commonwealth of Virginia requires that all incoming full time students at Roanoke College be vaccinated against meningococcal disease and, as of March 20, 2005, also Hepatitis B disease. Those who choose not to be vaccinated must sign a waiver indicating that they have received information on the risks of meningococcal and Hepatitis B diseases and the availability and effectiveness of the vaccines. Please review the information below which provides information and the availability of an effective vaccine for both diseases. Complete the documentation required on the immunization record by indicating the date on which you were vaccinated or by signing the waiver. Incoming undergraduate and transfer students who have not provided additional required vaccination documentation or signed the waiver(s) will be prevented from getting first choice when registering for classes. Meningococcal disease is a potentially fatal bacterial infection commonly referred to as meningitis. Meningococcal disease is rare; however its initial flu like symptoms make diagnosis difficult. If not treated early, the disease can lead to brain damage, vital organ failure, permanent disability and even death. Cases of meningococcal disease among teens and young adults 15 to 24 years of age have more than doubled since Recent studies indicate that college students living in residence halls and particularly freshmen residents are at increased risk of infection. An estimated 100 to 125 cases of meningococcal disease occur on college campuses each year. Of those students infected, as many as 15 may die. The meningococcal vaccine protects against four of the five strains of the bacteria which cause meningococcal disease (strains A, C, Y, and W 135). The vaccine is considered safe and is well tolerated with the most common side effect being soreness at the injection site. Hepatitis B is caused by a virus that attacks the liver. The Hepatitis B virus (HBV) can cause lifelong infection, cirrhosis (scarring) of the liver, liver cancer, liver failure, and death. HBV is spread when blood or body fluids from an infected person enters the body of a person who is not infected. Hep B is not spread through food or water, sharing eating utensils, hugging, kissing, coughing, sneezing, or by casual contact. HBV is spread through having sex with an infected person without using a condom or by sharing drugs or needles. Hep B vaccine is the best protection and is the first anti cancer vaccine because it can prevent a form of liver cancer. One out of 20 people in the United States will be infected with HBV sometime during their lives. The Hepatitis B vaccine is safe and effective and over 4 million adults in the United States have received the vaccine. The vaccination schedule most often used for adults has been three intramuscular injections, the second and third administered 1 and 6 months after the first. Additional information can be obtained on the Centers for Disease Control and Prevention (CDC) website at (select meningococcal and/or Hepatitis B) or the American College Health Association website at 4

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