All Students Full & Part-time. International Students. Recommended for All Students. Dear Student,

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1 Dear Student, Enclosed with this mailing you will find a health history form and requirements you need to take care of prior to arriving on campus. Please follow the instructions carefully. Submitting incomplete forms may result in delays in confirming your registration. The Student Health Center is available to all students enrolled in four or more credit hours, regardless of insurance. Please complete the Health History and TB questionnaire forms and return them by mail to us by July 1, o Our mailing address is th St. Golden, CO o For questions, please call o Page one of the Health History should be completed by the student, as well as the TB questionnaire. o Page two is a physical examination page. THIS IS NOT REQUIRED, however having this information available allows us to have more complete information when you come in for a visit. Sincerely, o o Page three should be left blank Page four must be completed by a health care professional, or you may attach an official record of your immunizations that has been signed by a health care professional. DO NOT fax or tear the original. This is becomes your official medical record in our office, and must stay in one piece. Debra Roberge, NP Director, Student Health Center All Students Full & Part-time International Students Recommended for All Students 2 MMR (Measles, Mumps, & Rubella) Tuberculosis Screening 2 MMR (Measles, Mumps, & Rubella) Tuberculosis Screening Hepatitis A Hepatitis B Meningitis Adacel/Tdap Gardasil Immunization Requirements Two doses given after the 1st birthday, and at least one month apart are required of all students born after Full dates (month/day/year) must be given for these. OR Positive blood tests showing immunity for Measles, Mumps and Rubella are accepted. History of illness does not meet this requirement. *A registration hold will be placed on students that are not compliant TB questionnaire must be completed prior to arrival. If indicated, a PPD test and/or IGRA test must be done, and results recorded on questionnaire. This is required. Refer to "All Students" section above for details. *A registration hold will be placed on students that are not compliant TB questionnaire must be completed prior to arrival. If indicated, a PPD test and/or IGRA test must be done, and results recorded on questionnaire. Two dose series given 6-12 months apart. Students who travel abroad are encouraged to consider this vaccine. Three dose series (good for life). This vaccine is especially encouraged for students who will be living in resident halls. Persons traveling to endemic countries also need to consider receiving this vaccine. One dose within the last 10 years. A three dose series (good for life).

2 PLEASE!!! DO NOT IGNORE THIS MESSAGE! Colorado law required that all students have an immunization record on file before enrolling in class. You will not be able to register for class if you have not submitted a record with exact dates you were given immunizations for measles, mumps and rubella or have signed a waiver stating you have a personal or religious belief against immunizations. If you have questions, call and speak with one of the nurses at the Student Health Center

3 NAME Coulter Student Health Center Golden, CO HEALTH HISTORY LAST (FAMILY) FIRST MIDDLE INITIAL CWID# DATE OF BIRTH PLACE OF BIRTH SEX: F M HOME ADDRESS HOME PHONE NUMBER NUMBER AND STREET NAME CITY STATE ZIP CODE MOBILE PHONE NUMBER EMERGENCY CONTACT NAME RELATIONSHIP PHONE NUMBER I PLAN TO ENROLL IN (check one) FALL SPRING SUMMER SEMESTER YEAR PERSONAL HISTORY check box if your answer is yes. Acne problem Depression Hearing loss Rheumatic fever ADD/ADHD Diabetes Heart problems Scoliosis Anemia Diarrhea Hemorrhoids Seizures/convulsions Anorexia Nervosa Dizziness/vertigo Hepatitis/liver problem Shortness of breath Arthritis/Rheumatism/Bursitis Ear/nose/throat problem High blood pressure Shoulder dislocation Asthma Eye problem Insomnia Skin problem Back problem Fainting/syncope Kidney stone Thyroid disease Binge eating episodes Frequent headaches/migraines Kidney/bladder infection Tobacco use Bone/joint injury/deformity Frequent vomiting Knee problems Tumor/cyst (benign) Cancer, type: Frequent worry/anxiety Mononucleosis Ulcer (duodenal or stomach) Chemical dependency Gall bladder problem/gallstones Neck problem Unexplained weight loss/gain Chronic sinusitis Gout Recurrent abdominal pain Use of laxatives, diuretics or vomiting Constipation Head injury/concussion to control weight MEDICATION ALLERGIES OTHER ALLERGIES Have you ever had any illnesses/injuries other than those noted (if yes, specify)? Have you had any operations (if yes, what type and how old were you)? Do you have any type of disability/condition which limits functioning (if yes, specify)? Please list any drugs, medicines, vitamins, minerals, supplements you use: FAMILY HISTORY Have any of your relatives ever had any of the following (please state relationship ie: grandfather, aunt, cousin)? Addiction (include type) Asthma Blood disease (include type) Cancer (include type) Diabetes Heart disease High blood pressure Mental illness Stroke Tuberculosis This is to certify that the above information is correct to the best of my knowledge. Student Signature Date TO PARENT OR GUARDIAN OF MINOR STUDENTS: I consent to have my son/daughter receive routine treatment at the Coulter Student Health Center or local hospital should he/she become ill or injured while at school. Parent/Guardian Signature Date

4 MEDICAL EXAMINATION (Optional) NAME OF STUDENT LAST FIRST MI AGE DATE OF EXAMINATION TO BE FILLED IN BY THE PHYSICIAN HEIGHT (in feet/inches) WEIGHT (in lbs) VISION BLOOD PRESSURE PULSE HEARING Corrected Right 20/ Left 20/ Right Ear Uncorrected Right 20/ Left 20/ Left Ear Color Vision Test Used Enclose Audiogram if indicated Labs as indicated CLINICAL EVALUATION Check each item in appropriate column Normal Abnormal 1. Skull, Scalp, Face, Neck, Thyroid 2. Nose and Sinuses 3. Mouth (tongue, gingvae, teeth) 4. Throat and Tonsils 5. Ears (Int. and Ext. Canals) 6. Eyes (pupils, E.O.M., conjunct.) 7. Lungs and Chest (include breasts) 8. Heart (rhythm, sounds, murmurs) 9. Abdomen and Viscera (include hernia) 10. Anus and Rectum (prostate if indicated) 11. Endocrine System 12. G-U System (results of pap if indicated) 13. Upper Extremities 14. Lower Extremities 15. Feet (flat, pain, infection) 16. Skin, Other Musculoskeletal 17. Skin, Lymphatic Glands 18. Neurologic NOTES Describe any abnormality in detail below Psychiatric (specify any known personality 19. disorder) SUMMARY OF EXAMINATION & RECOMMENDATION (for treatment, restrictions, etc.): PERTINENT PAST MEDICAL HISTORY: THE IMMUNIZATION RECORD IS REQUIRED BY COLORADO STATE LAW. PLEASE COMPLETE ON PAGE 4. To my knowledge, the above information is accurate and complete. Signature of Provider Date Print, type or stamp name in addition to signature Address -2-

5 Colorado School of Mines Coulter Student Health Center Golden, CO STUDENT NAME Last First Middle Initial MEDICATION ALLERGY Phone: Birth Date: DATE/TIME NURSING/MEDICAL/STAFF NOTES S O A P Subjective Objective Findings Findings Assessment Plans SIGNATURE -3-

6 AND UNION CONSTITUTION Colorado Department of Public Health and Environment Name: CERTIFICATE OF IMMUNIZATION FOR COLLEGE STUDENTS Colorado law requires this form be completed and provided to the school. Date of Birth: Student ID: Street Address: School Name: School Phone Number: City, State, ZIP Code: School Address: School Fax Number: Immunization requirements for Colorado college students: two doses of MEASLES, MUMPS, and RUBELLA (MMR) vaccine. REQUIRED VACCINE DATE GIVEN REQUIRED VACCINE DATE GIVEN MMR #1 (Measles-Mumps-Rubella) MMR #2 (Measles-Mumps-Rubella) The following vaccines are strongly recommended for college students, although not required by Colorado law. ADDITIONAL VACCINES RECOMMENDED DATES GIVEN (IF AVAILABLE) ADDITIONAL VACCINES RECOMMENDED DATES GIVEN (IF AVAILABLE) DTP/DTaP/Tdap (Diphtheria-Tetanus-Pertussis) Varicella (Chickenpox) Td (Tetanus-Diphtheria) Meningococcal OPV/IPV (Polio) HPV (Human Papillomavirus) Hep B (Hepatitis B) Other: Hep A (Hepatitis A) Other: Measles, mumps, and rubella (MMR) vaccine is not required for college students born before January 1, The first MMR vaccine must have been administered no earlier than 4 days before the first birthday. The 2 nd dose of MMR vaccine or of measles vaccine must have been administered at least 28 calendar days after the 1 st dose. In lieu of immunization, written evidence of laboratory tests showing immunity to measles, mumps, and rubella is acceptable. Attach written proof to the Certificate or record test results and dates in the boxes above. TO THE BEST OF MY KNOWLEDGE, THE PERSON NAMED ABOVE HAS RECEIVED THE IMMUNIZATIONS REQUIRED FOR SCHOOL/CHILD CARE ENTRY DO NOT SIGN UNLESS ALL REQUIRED IMMUNIZATIONS HAVE BEEN ADMINISTERED Signed Title Date (Physician, nurse or school health authority) STATEMENT OF EXEMPTION TO IMMUNIZATION LAW (DECLARACIÓN RESPECTO A LAS EXENCIONES DE LA LEY DE VACUNACIÓN) IN THE EVENT OF AN OUTBREAK, EXEMPTED PERSONS MAY BE SUBJECT TO EXCLUSION FROM SCHOOL AND TO QUARANTINE. SI SE PRESENTA UN BROTE DE LA ENFERMEDAD, ES POSIBLE QUE A LAS PERSONAS EXENTAS SE LES PONGA EN CUARENTENA O SE LES EXCLUYA DE LA ESCUELA. MEDICAL EXEMPTION: The physical condition of the above named person is such that immunization would endanger life or health or is medically contraindicated due to other medical conditions. EXENCIÓN POR RAZONES MÉDICAS: El estado de salud de la persona arriba citada es tal que la vacunación significa un riesgo para su salud o incluso su vida; o bien, las vacunas están contraindicadas debido a otros problemas de salud. Medical exemption to the following vaccine(s): La exención por razones médicas aplica a la(s) siguiente(s) vacuna(s): Signed (Firma) Date (Fecha) Physician (Médico) RELIGIOUS EXEMPTION: Parent or guardian of the above named person or the person himself/herself is an adherent to a religious belief opposed to immunizations. EXENCIÓN POR MOTIVOS RELIGIOSOS: El padre o tutor de la persona arriba citada, o la persona misma, pertenece a una religión que se opone a la inmunización. Religious exemption to the following vaccine(s): Exención por motivos religiosos de la(s) siguiente(s) vacuna(s): Signed (Firma) Date (Fecha) Parent, guardian, emancipated student or student 18 years and older (Padre, tutor, estudiante emancipado o estudiante de 18 años y mayor) PERSONAL EXEMPTION: Parent or guardian of the above named person or the person himself/herself is an adherent to a personal belief opposed to immunizations. EXENCIÓN POR CREENCIAS PERSONALES: Las creencias personales del padre o tutor de la persona arriba citada, o la persona misma, se oponen a la inmunización. Personal exemption to the following vaccine(s): Exención por creencias personales de la(s) siguiente(s) vacuna(s): Signed (Firma) Date (Fecha) Parent, guardian, emancipated student or student 18 years and older Form Apprvd. 11/03 CDPHE-IMM CI-C RC Rev. 8/07 (Padre, tutor, estudiante emancipado o estudiante de 18 años y mayor)

7 TUBERCULOSIS SCREENING FORM Name: Date: CWID: Place of Birth: Please answer the following questions: 1. Have you ever had a positive TB skin test (PPD)? Yes No 2. Have you ever been given medication to prevent or treat active TB? Yes No If yes, which medication did you take? For how long? 3. Have you ever had close contact with anyone who was sick with TB? Yes No 4. Have you ever lived/worked in a nursing home, jail or homeless shelter? Yes No 5. Have you ever been vaccinated with BCG? Yes No 6. Were you born in one of the countries listed below and arrived in the U.S. Yes No within the past 5 years? (if yes, please CIRCLE the country) 7. Have you ever traveled* to/in one or more of the countries listed below? Yes No (If yes, please CIRCLE the country/ies) *The significance of the travel exposure should be discussed with a health care provider and evaluated. Afghanistan Cook Islands Japan Nepal Sri Lanka Algeria Côte d Ivoire Kazakhstan Nicaragua St. Vincent & the Grenadines Angola Croatia Kenya Niger Sudan Argentina D.P. R. of Korea Kiribati Nigeria Suriname Armenia D.R. of the Congo Kuwait Pakistan Swaziland Azerbaijan Djibout Kyrgyzstan Palau Syrian Arab Republic Bahrain Dominican Republic Laos Panama Taiwan Bangladesh Ecuador Latvia Papua New Guinea Tajikistan Belarus El Salvador Lesotho Paraguay Tanzania Belize Equatorial Guinea Liberia Peru Thailand Benin Eritrea Libyan Arab Jamahiriya Philippines Timor-Leste Bhutan Estonia Lithuania Poland Togo Bolivia Ethiopia Macedonia Portugal Tonga Bosnia and Herzegovina French Polynesia Madagascar Qatar Trinidad and Tobago Botswana Gabon Malawi Republic of Korea Tunisia Brazil Gambia Malaysia Republic of Moldova Turkey Brunei Darussalam Georgia Maldives Romania Turkmenistan Bulgaria Ghana Mali Russian Federation Tuvalu Burkina Faso Guam Marshall Islands Rwanda Uganda Burundi Guatemala Mauritania Sao Tome and Principe Ukraine Cambodia Guinea Mauritius Senegal Uruguay Cameroon Guinea-Bissau Micronesia Serbia Uzbekistan Cape Verde Guyana Mongolia Seychelles Vanuatu Central African Republic Haiti Montenegro Sierra Leone Venezuela Chad Honduras Morocco Singapore Viet Nam China India Mozambique Solomon Islands Yemen Colombia Indonesia Myanmar Somalia Zambia Comoros Iraq Namibia South Africa Zimbabwe Congo Source: World Health Organization Global Health Observatory, Tuberculosis Incidence Countries with incidence rates of 20 cases per 100,000 population. For future updates, refer to Student Signature: (Parent/Guardian signature if under 18) Date: If you answered Yes to any of the questions 3-7, Colorado School of Mines requires that you get a TB skin test (PPD) or Interferon Gamma Release Assay (IGRA) unless a previous test has been documented. The following information must be completed by a Physician's office. Tuberculin Skin Test (Mantoux only; no tine tests) Date Given: Date read: Result: mm Record actual mm of induration, transverse diameter; if no induration, write "0" Interferon Gamma Release Assay (IGRA) Date Obtained: Method: QFT-G QFT-GIT T-Spot Other Result: Negative Positive Indeterminate Borderline(T-Spot only) Chest x-ray (required if PPD or IGRA is positive) Date of chest x-ray: Result: Normal Abnormal Physician or Nurse Signature: Date: