STUDENT HEALTH SERVICES 204 College Rd, Hampden-Sydney, VA 23943

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Page 1 STUDENT HEALTH SERVICES 204 College Rd, Hampden-Sydney, VA 23943 NEW STUDENT HEALTH FORM The staff at Student Health are dedicated to providing you with high-quality health care designed specifically to meet the needs of college students; however, we need your help to do our job well. It is necessary for us to have an accurate health record for each of our students; this record must be completed and returned to Student Health by August 1. INSTRUCTIONS: 1. Complete pages 1, 2, and 4 yourself or with the help of your family. 2. Make an appointment for a physical examination with your health care provider. Have them fill in pages 3, 5, and 6. 3. Make a copy of your complete record for your files, then return the completed form to: Student Health PO Box 336, Hampden-Sydney College, Hampden-Sydney, Virginia 23943 (434) 223-6167 FAX (434) 223-7071 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 that you or your health care provider include on this form with the Director of Counseling, the Director of Sports Medicine or Head Athletic Trainer, the Assistant Dean of Students for Substance Abuse, and/or the Associate Dean for Academic Support. I do give my permission for the information on this form to be shared as described above. I do not give my permission for the information on this form to be shared as described above. Signed Date Student s full name Nickname Address Telephone City State Zip Date of Birth / / Circle one: Freshmen Transfer Religion (optional) IN CASE OF EMERGENCY, please notify: Name Relationship Address City State Zip Home phone Business phone E-mail address Other phone # s Fax # if available EMERGENCY TREATMENT In the case of an extreme emergency, I give permission to the Dean of Students, or his designee, of Hampden-Sydney College to sign a consent for emergency treatment when in the best judgment of medical personnel further delay would jeapardize the life or health of. Every reasonable effort will be made to contact a family member before this authorization is used. Student s signature Date Parent or guardian s signature (if student is under 18 years of age)

Page 2 FAMILY HISTORY General Family Health Status: Mother Father Siblings If deceased, give age and cause of death Which of your blood relatives have had any of the following? High Blood pressure Heart Disease Kidney Disease Alcoholism Diabetes Mental Illness Tuberculosis Cancer Seizure Disorder Stroke Other serious illnesses (please specify) YOUR PERSONAL HISTORY Have you ever been told that you have or have had any of the following? (Please circle all that apply) ADD/ADHD Alcohol or other drug problems Anxiety Disorder Appendicitis Asthma Arthritis Chicken Pox Colitis or Irritable Bowel Concussion Depression Diabetes Hearing Impairment Heart Problems Hepatitis High Blood Pressure Suppressed immune system Kidney problems Learning Disability Mono Orthopedic problems Seizure Disorder Thyroid Problems Tuberculosis Ulcers Vision problems Other disease or disorder Do you now or have you ever experienced any of the following? (Please circle all that apply) Seasonal allergies Chest pain Convulsions Frequent diarrhea Recurrent earaches Excessive thirst Fluttering or racing heartbeat Frequent, severe headaches Frequent head colds Frequent inability to concentrate Feelings of loneliness or despair Recurrent pain (where? ) Skin disorders Sleepwalking Frequent sore throat Frequent vomiting Unexplained weight loss or gain Head injury HAVE YOU HAD ADVERSE (BAD) OR ALLERGIC REACTIONS TO ANY MEDICATIONS? NO YES If yes, to what medication(s)? OTHER ALLERGIES (list) (If yes, how do you treat these allergies?) SURGERY AND SERIOUS ILLNESS (please explain and give dates) CURRENT HEALTH PROBLEMS AND MEDICATIONS THAT YOU ARE NOW TAKING (please list)

THIS PAGE MUST BE COMPLETED BY YOUR HEALTH CARE PROVIDER Page 3 Student s name Date of Birth Health Care Provider s name Phone # Health Care Provider s address City State Zip Height Weight Blood Pressure Pulse regular/irregular Vision Hearing Urinalysis (when indicated) CBC (when indicated) MEDICATION ALLERGIES PHYSICAL ASSESSMENT (If necessary, please continue on page 4) Normal Abnormal (Please explain) Head, ears, nose, and throat Respiratory Cardiovascular Gastrointestinal Hernia Genitourinary Musculoskeletal Endocrine/metabolic Neuropsychiatric Skin Teeth Thyroid Orthopedic Other Testicular Self-Examination explained? Yes No TUBERCULOSIS SCREENING (when appropriate for high-risk students according to CDC guidelines) 1. PPD (Mantoux) within the past 12 months Result: Neg Pos mm / / Mo Day Yr 2. If PPD is positive, chest X-ray required: X-ray result: Normal / Abnormal Date / / FOLLOW-UP TREATMENT (when appropriate): General comments This student is capable of strenuous activities including varsity athletics. This student needs further evaluation before participating in strenuous activities. This student should not participate in strenuous activities. Please explain Is this student being treated at this time for any medical or emotional problems? No Yes (if yes, please explain) Health Care Provider s signature Date

Page 4 INSURANCE INFORMATION (Please make sure that you have a personal copy of your health insurance information; that information should be as handy as your driver s license.) You are responsible for the cost of your medical care while you are at Hampden-Sydney College. With very few exceptions, there is no charge for the services provided at the Health Center, including treatment provided by the College Physician; however, you will be responsible for all of your other medical expenses, including prescription drugs. If your private health insurance is through a managed care plan such as an HMO, please contact that provider to ensure that you will be covered conveniently while you are at college. The Health Center does not routinely accept the responsibility of contacting primary care providers for referrals. The Health Center does not file claims with any insurance carriers. We also encourage you to plan for expenses such as prescription drugs; the cost of medications is frequently not covered by insurance plans. Please attach a copy of your insurance information to this form (front and back). Please notify the Health Center if your insurance changes. I. Name of Insurance Company Phone #s (1) (2) Address If applicable, other Information from your insurance card: Group # Name of Policy Holder Group where insured Identification # Additional Information STUDENTS WITH SPECIAL NEEDS Students who have physical limitations that may require special environmental accommodations should contact the Office of Student Affairs at (434) 233-6128 and the Disability Coordinator at (434) 223-6324. Students who have documented learning difficulties and who may need special academic considerations, should contact the Associate Dean for Academic Support at (434) 223-6324.

Page 5 Student s Name Date of Birth / / Mo Day Yr TO BE COMPLETED AND SIGNED BY YOUR HEALTH CARE PROVIDER. All information must be in English. REQUIRED A. MMR (MEASLES, MUMPS, RUBELLA) 1. Dose 1 given at age 12 months or later...#1 / / 2. Dose 2 given at least 28 days after first dose...#2 / / B. TETANUS, DIPHTHERIA, PERTUSSIS 1. Primary series completed? Yes No Date of last dose in series: / / 2. Date of most recent booster dose: / / Type of booster: Td Tdap C. POLIO 2. IPV/OPV series completed / / STRONGLY RECOMMENDED A. MENINGOCOCCAL QUADRIVALENT (A, C, Y, W-135) 1. Quadrivalent conjugate (preferred; administer simultaneously with Tdap if possible). a. Dose #1 / / b. Dose #2 / / 2. Quadrivalent polysaccharide (acceptable alternative if conjugate not available). Date / / B. SEROGROUP B MENINGOCOCCAL The vaccine series must be completed with the same vaccine. 1. MenB-RC (Bexsero) routine outbreak related a. Dose #1 / / b. Dose #2 / / OR 2. MenB-FHbp (Trumenba) routine outbreak-related a. Dose #1 / / b. Dose #2 / / c. Dose #3 / / C. INFLUENZA Trivalent (IIV3) Quadrivalent (IIV4) Recombinant (RIV4) Live attenuated influenza vaccine (LAIV) Adjuvanted inactivated influenza (aiiv3) Date of last dose: / /

Page 6 D. HEPATITIS A 1. Immunization (hepatitis A) a. Dose #1 / / b. Dose #2 / / 2. Immunization (Combined hepatitis A and B vaccine) a. Dose #1 / / b. Dose #2 / / c. Dose #3 / / E. HEPATITIS B Heplisav-B (2 dose series) is not interchangeable with other hepatitis B vaccines (3 dose series) but can substituted for dose #2 and #3. 1. Immunization (hepatitis B) a. Dose #1 / / b. Dose #2 / / c. Dose #3 / / Adult formulation Child formulation Adult formulation Child formulation Adult formulation Child formulation HepB-CpG (Heplisav-B) HepB-CpG (Heplisav-B) HepB-CpG (Heplisav-B) 2. Immunization (Combined hepatitis A and B vaccine) a. Dose #1 / / b. Dose #2 / / c. Dose #3 / / 3. Hepatitis B surface antibody (recommended for individuals born in or whose mother was born in a hepatitis B endemic country and/or men who have sex with men; required for health science students). Date / / Result: Reactive Non-reactive F. HUMAN PAPILLOMAVIRUS VACCINE Immunization (indicate which preparation, if known) Quadrivalent (HPV4) or Bivalent (HPV2) or 9-valent (HPV9) a. Dose #1 / / b. Dose #2 / / c. Dose #3 / / G. VARICELLA 1. Immunization a. Dose #1...#1 / / b. Dose #2 given at least 12 weeks after first dose ages 1 12 years...#2 / / and at least 4 weeks after first dose if age 13 years or older. 2. History of Disease Yes No or Birth in U.S. before 1980 Yes No H. PNEUMOCOCCAL POLYSACCHARIDE VACCINE PCV 13 Date / / PPSV 23 Date / / HEALTH CARE PROVIDER Name Signature Address Phone ( ) Hampden-Sydney College PO Box 336 Hampden-Sydney, VA 23943 P (434) 223-6167 F (434) 223-7071

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