WHEATON COLLEGE STUDENT HEALTH SERVICES MEDICAL FORMS

Transcription

1 WHEATON COLLEGE STUDENT HEALTH SERVICES MEDICAL FORMS MyWheaton.edu is the official communication of Wheaton College. Please be sure to check your Wheaton College regularly for updates on your submitted health requirements and other college announcements. Requirements Who to Fill Out Action Who to Page 2 Medical History Page 3 Physical Examination Page 4 Section I Tuberculosis Screening Questionnaire Page 5 Section II Required Immunizations Page 6 Tuberculosis Screening Supplement The Student* *Parent is to fill out form if student is a minor. Medical Doctor, Physician Assistant, or Nurse Practitioner with office stamp The Student Medical Doctor, Physician Assistant, or Nurse Practitioner with office stamp OR can submit official record of immunizations from office Medical Doctor, Physician Assistant, or Nurse Practitioner with office stamp* *Required only if MD, PA, or NP administers TB Test. 4 easy ways to submit your forms: Drop off at SHS in person at North Harrison Hall 800 Centennial Dr, Suite 130 Wheaton, IL Postmarked on/before July 5, 2018 Mail to: Wheaton College Student Health Services 501 College Avenue Wheaton, IL Completed form * *Required only if MD, PA, or NP administers TB Test. Deadline Student July 5, Student or Doctor July 5, Student July 5, Student or Doctor Student and Doctor July 5, July 5, Need More Time for Certain Requirements? June 15, 4pm June 15, 4pm June 15, 4pm June 15, 4pm June 15, 4pm Incomplete Student Health Services Requirements: If health entrance forms are not completed and submitted by the deadline of July 5,, a late fee of $ and/or a registration hold may be placed on the student s account. Ph: to student.health.services@wheaton.edu #Extension requests are approved at the discretion of the SHS staff. Fax to: Key to Who Fills Out Forms Blue= Student Yellow= Medical Doctor, Physician Assistant, or Nurse Practitioner 1

2 WHEATON COLLEGE STUDENT HEALTH SERVICES MEDICAL HISTORY REPORT To be completed by Student/ Parent: (All information must be in English) Name: ID# Last name First name MI Preferred name Address: Street City State Zip Student s cell phone Date of Entry: / Date of Birth: / / Sex: M F _ Mo Yr Mo Day Yr Maiden Name Status: Part-time Full-time Graduate Undergraduate Consortium Modular ELIC Spouse of student Employee Campus: Wheaton College HoneyRock/Northwoods Science Station Black Hills Study Abroad Program Have you previously attended Wheaton College? Yes No If yes, last year of attendance Maiden Name In case of Emergency Notify: (Minors must fill this out Name Address Relationship to student with guardian in the USA) Home Phone (with area code) Cell Phone (with area code) Work Phone (with area code) FAMILY HISTORY Age Father Mother Siblings Spouse Children State of Health Occupation Age of Death Cause of Death Immediate Family Medical History Autoimmune disease Cancer Diabetes Heart Disease Kidney Disease Seizures Stroke Tuberculosis Psychiatric/mental health disease Family history of sudden death before age 50 (cause unknown) Yes No Relationship PERSONAL HISTORY: Please comment on all yes answers in comment section or on an additional sheet. Have You Had? Y N Y N Y N Y N ADD/ADHD Depression/Anxiety Malaria Sinus condition Anemia Diabetes Menstrual problems Sleep Disturbance Asperger Syndrome Disordered Eating Mononucleosis Stomach Disorder Asthma Eye problem Orthopaedic Strep throat, recurrent Back Problem Gallbladder disease Pneumonia Surgery Bipolar Disorder Head injury POTS Appendectomy Bronchitis, recurrent Headache, recurrent PTSD Tonsillectomy Cancer Heart condition/murmur Recent International Travel Other Celiac Disease Hepatitis Recurrent Concussions Thyroid disorder Chickenpox High Blood Pressure Seizures Tuberculosis Counseling HIV/AIDS Self Harm Urinary tract infection Crohn s/ulcerative Colitis Kidney disorder Sexually transmitted disease Weight gain/loss, recent COMMENTS: HOSPITALIZATIONS/SURGERY: None Reason(s) _Date(s) List allergies to medications, foods, pollen, molds, other: None List medications/herbals taken regularly: None_ List accessibility needs: Other: Student s Signature (Required) Date PARENTAL CONSENT: If your student is <18 years of age, please complete the Consent for Minors, found on the SHS website. Website: Student.Health.Services@wheaton.edu Phone: Fax: PHYSICAL EXAMINATION 2

3 Physical examination must be within one year prior to date of entrance. TO THE EXAMINING CLINICIAN. Please review the student s history, complete the physical examination form, and comment on all positive answers. This student has been accepted to Wheaton College. The information supplied will not affect status; it will be used only as a background for providing health care, if necessary. It is strictly for the use of Student Health Services, and will not be released without the student s consent. Please add any laboratory diagnostic exams that are age/medical history appropriate. Please ensure name and date of birth are on every page. Name Student ID # M F Date of Birth Wt. Ht. BMI Pulse B/P Please utilize the CDC.gov BMI calculator LMP date: Regular Yes No How many periods in a year? Medications: Allergies: Contact Lenses Yes No Glasses Yes No Vision: Corrected: Uncorrected: R 20/ L 20/ Food Allergies: CLINICAL EVALUATION Check each item in appropriate column, at right. Enter N.E. if not evaluated. 1. SKULL, SCALP, FACE, NECK, THYROID 2. NOSE and SINUSES 3. MOUTH (tongue, gingivae, teeth) 4. THROAT and TONSILS 5. EARS (Int. and Ext. Canals) 6. EYES (pupils, E.O.M., conjunctiva) 7. LUNGS and CHEST (include breasts) 8. HEART (rhythm, sounds, murmurs. Examine in sitting, recumbent, and left recumbent positions before and after exercise.) 9. ABDOMEN and VISCERA (include hernia) 10. ENDOCRINE SYSTEM 11. G-U SYSTEM (optional) 12. MUSCULOSKELETAL 13. FEET (flat, pain, infection) 14. SKIN 15. LYMPHATIC GLANDS 16. NEUROPSYCHIATRIC Normal Abnormal REMARKS OR ADDITIONAL INFORMATION Do you have any recommendations regarding the care of this student? Yes No If yes, explain REQUIRED: Recommendations for physical activity for Intramurals or Club Sports (not intercollegiate), travel abroad, general education requirements, internships. (Please complete or student cannot compete/participate): Unlimited Limited No PE Explain: If this student is an intercollegiate athlete they must complete a sickle cell screen blood test. The results must be attached; otherwise, the athlete may not be able to participate. For further information, visit NCAA.org. To request a waiver for this test, please contact the Wheaton College Athletic Department at Clinician s Signature Date Phone Clinician s name (please print or use stamp) Address Acceptable medical clinician to complete the physical exam is a physician (M.D., D.O.), physician assistant or a nurse practitioner FAX: CERTAIN IMMUNIZATIONS ARE REQUIRED BY THE STATE OF ILLINOIS FOR ALL INCOMING COLLEGE STUDENTS. PLEASE COMPLETE THE IMMUNIZATION AND TUBERCULOSIS SCREENING CERTIFICATE ON THE NEXT TWO PAGES. THIS CERTIFICATE MUST BE SIGNED BY A HEALTHCARE PROVIDER. Key to Who Fills Out Forms Blue= Student Yellow= Medical Doctor, Physician Assistant, or Nurse Practitioner 3

4 Name: Student ID # Date of Birth: TUBERCULOSIS (TB) SCREENING QUESTIONNAIRE SECTION I **Student must fill this out completely including explanations. Prior Testing: When was your last TB skin test (PPD)? Results: Negative Positive N/A When was your last TB blood test (IGRA)? Results: Negative Positive N/A (include report) If yes to the any of the following, please describe: 1. Have you ever been told by a doctor or healthcare provider that you had active TB? 2. Have you ever taken medication for TB? Which medication(s)? What year? 3. Have you ever had a BCG vaccine for TB? (BCG does not exempt you from this requirement) 4. Have you ever been told by a health care provider that your immune system is not working right or that you cannot fight infection? (e.g. immune disorder or illness) 5. Have you cared for, or lived with, anyone diagnosed with active TB disease in the past year? 6. Have you worked or volunteered in a setting where TB may be more common, such as a homeless shelter, nursing home, group home, or prison, in the past year? Explanation 7. Have you travelled outside the USA in the past year? If yes, answer #8 8. Where? Length of stay? Date of return 9. In what country were you born? In USA since what year? 10. Have you received a live vaccine in the past 6 weeks? (e.g. measles, mumps, rubella, chickenpox, or shingles) Have you experienced any of the following symptoms? Y N Have you experienced any of the following symptoms? Y N 11. Persistent coughing (3 weeks or more) 12. Unexplained weight loss? 13. Coughing up blood or bloody sputum 14. Unexplained, excessive fatigue? 15. Night sweats (soak the sheets) 16. Fever of unknown origin? SECTION II If you answered yes to the above, SHS will review the form and reply to your my.wheaton account for your individual treatment plan to be completed prior to the entrance deadline. Treatment may include a PPD skin test or an IGRA blood test. Note to Medical Providers, please see Tuberculosis Screening Supplement (page 5): if PPD positive, IGRA positive, or student answers yes to certain questions. REQUIRED IMMUNIZATIONS Please fill out form in English. Also, please make sure month, date, and year are filled out. If needed, please attach an official document in lieu of filling this out. *TETANUS/DIPHTHERIA/PERTUSSIS Primary series (3-4 doses) with Diphtheria, Pertussis and Tetanus (DTP) or Diphtheria and Tetanus (TD or DT) AND a booster within the past ten years. DIPHTHERIA, PERTUSSIS, TETANUS or DIPHTHERIA, TETANUS #1 _ #2 #3 #4 *MENINGITIS CONJUGATE (Menactra, MenHibrix, Menveo) Required on or after age 16 years. *MCV4 (Menactra or Menveo) LATEST BOOSTER *M.M.R. (Measles, Mumps, Rubella) Two doses of M.M.R. at least 28 days apart after 12 months old. Born before 1957, no immunization required. M.M.R. (MEASLES, MUMPS, RUBELLA) #1 #2 *Tdap *Consider Tdap/Adacel for Booster if appropriate Proceed to next page if M.M.R. requirement has been met. 4

5 Name: Student ID # Date of Birth: Fill out this portion ONLY IF M.M.R. requirement has not been met MEASLES (Rubeola): If given instead of M.M.R., two doses required. Dose #1 given 1/1/68 or later and after first birthday. (MMR is preferred for second dose see MMR section.) Dose #2 given at least 30 days after initial dose OR Report of Immune Titer.* MUMPS: If given instead of M.M.R., two doses required given 1/1/68 or later and after first birthday OR report of Immune Titer.* RUBELLA (German Measles): If given instead of M.M.R., one dose required given 1/1/68 or later and after first birthday OR Report of Immune Titer. * MEASLES MUMPS RUBELLA #2 #2 TITER RESULTS TITER RESULTS TITER RESULTS RECOMMENDED IMMUNIZATIONS *Attach copy of ALL lab reports in English. POLIO Recommended *Please circle which vaccine given OPV (oral) Or IPV (injected) #2 #3 #4 #5 HEPATITIS B Recommended (Three doses of vaccine OR a positive surface antibody) HEPATITIS B #1 #2 #3 IMMUNIZATION _ HEPATITIS B SURFACE ANTIBODY _ RESULT: REACTIVE NON-REACTIVE VARICELLA (CHICKENPOX) Recommended (Either a history of chicken pox, a positive Varicella antibody, or two doses of vaccine given at least one month apart) VARICELLA ANTIBODY _ HISTORY OF DISEASE YES NO OR DATE / / MM DD YEAR IMMUNIZATION RESULT: REACTIVE NON-REACTIVE #2 OTHER IMMUNIZATIONS RECEIVED (i.e. Hepatitis A, Typhoid, HPV, Yellow Fever, Meningitis B, Menomune, etc.) THIS CERTIFICATE MUST BE SIGNED BY A HEALTH CARE PROVIDER. (Physician, Nurse, or Health Department stamp) You may attach an official immunization certificate to this document. It must be signed by a licensed medical professional or carry the official logo/stamp of the organization. Required Medical Provider Signature Date _ Print Name Phone Fax: Address: Please return completed forms and records to: Wheaton College Student Health Services 501 E. College Ave Wheaton, IL (630) phone (630) fax student.health.services@wheaton.edu Immunization Exemption Policy By Illinois State law, a student may be exempt from immunizations for one of only two reasons: medical or religious. To request an immunization exemption form, please Student.Health.Services@wheaton.edu. The Director will contact you directly to discuss the process. All completed forms will be reviewed by the Director of Student Health Services for approval. This is part of the entrance requirements. Key to Who Fills Out Forms Blue= Student Yellow= Medical Doctor, Physician Assistant, or Nurse Practitioner 5

6 Wheaton College Student Health Services TB Screening Supplement for Medical Providers Patient Name / / Last First Date of birth Student ID number Dear Medical Provider, Please review the TB screening tool. If the student replies Yes to particular questions, the student may need to progress to certain testing. If the skin test (TST/PPD) is positive, an IGRA (QFT/T-Spot) should be completed. If the IGRA is positive, a chest x-ray should be completed. Please send all original lab and x-ray reports so that student s entrance medical chart requirement is not delayed. TST/PPD Date obtained / / Date read / / Month Day Year Month Day Year Results Interpretation Interferon Gamma Release Assay (IGRA) Date obtained / / (specify method): QFT T-Spot Month Day Year Result: negative positive indeterminate /borderline Report attached If positive, refer to CDC.gov rubric. Progress to IGRA testing If IGRA positive, progress to chest x-ray Chest X-ray: (Required if IGRA is positive) Date of chest x-ray / / Result: normal abnormal Report attached Month Day Year Medication Section: Were they advised to take medication because of the positive results? No Yes If yes, did they accept medication? No Yes If yes, what medication(s) were prescribed? _ Date Started: / / Date Ended: / / Additional Notes: 1. If BCG was received, a IGRA is preferred to a PPD. 2. If immune deficient, testing may be falsely negative and there is greater risk of progression from LTBI to active disease 3. If a live vaccine was recently received or patient is ill, consider delaying IGRA testing until 4-6 weeks after vaccination or illness to avoid a false positive result. 4. If PPD positive complete IGRA. If IGRA is positive, send chest x-ray results TUBERCULOSIS (TB) RISK ASSESSMENT- Management of Positive TST or IGRA All students with a positive IGRA with no signs of active disease on chest x-ray should receive recommendation to be treated for latent TB with appropriate medication. However, students in the following groups are at increased risk of progression from LTBI 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 transplant. 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 Health Care Provider Name Signature Address Fax Phone 6