WHEATON COLLEGE STUDENT HEALTH SERVICES MEDICAL FORMS MyWheaton.edu email is the official communication of Wheaton College. Please be sure to check your Wheaton College email regularly for updates on your submitted health requirements and other college announcements. Form Form Form Form Page 2 Medical History Page 3 Medical Examination* Page 4 Tuberculosis Screening Questionnaire Page 5 Tuberculosis Screening Supplement for Medical Providers* *If necessary Filled out by student* *Parent is to fill out Minor Consent if student is a minor on or after first day of school. *If past medical examination on file with SHS is 2 years old, student must get new medical examination. Filled out by Medical Doctor Filled out by student Filled out by Medical Doctor, Physician Assistant, or Nurse Practitioner with office stamp* *Required only if MD, PA, or NP administers TB Test. Submit form to SHS AND Athletics* *If you are an Intercollegiate Athlete, this form must also be sent to Athletics with other Athletic forms. Questions regarding other Athletic forms, call Athletics at 630-752- 5738. 4 easy ways to submit your forms: 1. Drop off at SHS in person at North Harrison Hall 800 Centennial Dr, Suite 130 Wheaton, IL 60187 2. Postmarked on/before May 23, 2019 Mail to: Wheaton College Student Health Services 501 College Avenue Wheaton, IL 60187 3. Email to student.health.services@wheaton.edu 4. Fax to: 630.752.5575 Incomplete Student Health Services Requirements: If health entrance forms are not completed and submitted by the deadline of May 23, 2019 by 11:59pm CST, a late fee of $100.00 and/or a registration hold may be placed on the student s account. Ph: 630.752.5072 Extension requests for submission of entrance medical requirement forms must be made from student s Wheaton College email by April 25, 2019 by 4pm CST and are approved at the discretion of the SHS staff. Website: www.wheaton.edu/shs Email: Student.Health.Services@wheaton.edu Phone: 630-752-5072 Fax: 630-752-5575 1
WHEATON COLLEGE STUDENT HEALTH SERVICES MEDICAL HISTORY REPORT To be completed by Wheaton College Student: (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: www.wheaton.edu/shs Email: Student.Health.Services@wheaton.edu Phone: 630-752-5072 Fax: 630-752-5575 2
WHEATON COLLEGE, IL MEDICAL EXAMINATION FORM This form will meet the medical exam requirement for general entrance and athletic participation. The medical examination must be within one year prior to date of entrance, unless student is an Intercollegiate Athlete, in which case the medical exam must be done 6 months or less prior to start of sport.. TO THE EXAMINING PHYSICIAN. Please review the student s medical history, complete the medical examination form, and comment on all abnormal answers. Please add any laboratory diagnostic exams that are age/medical history appropriate. 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: Check each item in appropriate column, at right. Enter N.E. if not evaluated. Clinical Evaluation Normal Abnormal Check each item in appropriate column, at right. Enter N.E. if not evaluated. Normal Abnormal 1. Appearance 16. Musculoskeletal Exam (all fields required for Intercollegiate Athletes) 2. Skull, Scalp, Face, Neck, Thyroid C-Spine 3. Nose and Sinuses Thoracic, Lumbar, Sacral Spine 4. Mouth (tongue, gingivae, teeth) Other 5. Throat and Tonsils Left Right 6. Ears (Int. and Ext. canals) Shoulder 7. Eyes (pupils, E.O.M., conjunctiva) Elbow 8. Lungs and Chest (include Breasts) 9. Heart (rhythm, sounds, and Murmurs. Examine in sitting, recumbent, and left recumbent positions before and after exercise.) 10. Abdomen/Pelvis and Viscera (include hernia) Wrist Hand/Fingers 11. Endocrine System Upper Leg 12. G-U System (optional for females) males: testes Knee 13. Skin Lower Leg 14. Lymphatic Glands Ankle 15. Nervous System Hip Feet/Toes Other: Required: Recommendations for physical activity for intercollegiate, intramurals, club sports, travel abroad, general education requirements, internships. (Please complete or student cannot compete/participate): Cleared without restriction Cleared, with recommendations for further evaluation or treatment for: Not Cleared for All Sports Certain Sports: Reason for Non-Clearance: Recommendations: If this student is an intercollegiate athlete, they must acknowledge education of sickle cell screening through blood test, waiver, or consent to testing. For further information, visit NCAA.org. To request a waiver for this test, please contact the Wheaton College Athletic Department at 630-752-5738. Physician s Signature Date Phone Physician s name (please print or use stamp) Fax Address Acceptable medical providers to complete the medical examination is a M.D. or D.O. Website: www.wheaton.edu/shs Email: Student.Health.Services@wheaton.edu Phone: 630-752-5072 Fax: 630-752-5575 3
Name: Student ID # Date of Birth: TUBERCULOSIS (TB) SCREENING QUESTIONNAIRE Student please fill out and submit form to SHS as this is part of your entrance medical requirements even if you have not had any prior testing. Prior Testing: Have you had a TB skin test (PPD)? No Yes If yes, result: Negative Positive Date: Have you had a TB blood test (IGRA)? No Yes If yes, result: Negative Positive Date: Please answer questions 1-16 and provide an explanation if the answer is YES. 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. In what country were you born? 8. If you were not born in the USA, since what year have you been in the USA? 9. Have you traveled outside the USA in the past year? If yes, please provide the following information. 10. Have you received a live vaccine in the past 6 weeks? (e.g. measles, mumps, rubella, chickenpox, or shingles) 11. Persistent coughing (3 weeks or more) 12. Coughing up blood or bloody sputum 13. Night sweats (soak the sheets) 14. Unexplained weight loss? 15. Unexplained, excessive fatigue? 16. Fever of unknown origin? SHS will review this form and reply to your my.wheaton email account if you need an individual plan for further testing or treatment. Treatment may include a PPD skin test(s) or an IGRA blood test. Depending on your individual plan, these services may be available through Student Health Services. For non-shs Medical Providers, please use TB SCREENING SUPPLEMENT FOR MEDICAL PROVIDERS (page 5) to provide additional documentation. Website: www.wheaton.edu/shs Email: Student.Health.Services@wheaton.edu Phone: 630-752-5072 Fax: 630-752-5575 4
TB SCREENING SUPPLEMENT FOR MEDICAL PROVIDERS This page should be provided to your medical provider if a new PPD skin test has been administered or an IGRA blood test has been completed based on the information on the TB Screening Questionnaire (page 4). Student please provide this supplement to your medical provider to complete if they administered/performed one of these tests. If you have prior testing or TB Treatment, please provide the official report(s). Patient Name / / Last First Date of birth Student ID number 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, an 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 Website: www.wheaton.edu/shs Email: Student.Health.Services@wheaton.edu Phone: 630-752-5072 Fax: 630-752-5575 5