STUDENT HEALTH SERVICES NEW STUDENT QUESTIONNAIRE UC Hastings Student Health Services (SHS) is committed to providing you the best possible medical care, so we need to know about your medical history and your medical needs. Please complete this mandatory form accurately and completely. It will become part of your SHS medical record. Please call SHS at 415 565 4612 at any time if you have questions about your health care needs. Your Student ID# can be found in Web Advisor or in your offer letter. Return this completed form by faxing it to 415 565 4607. You can also mail or personally deliver it to UC Hastings Student Health Services Department, 200 McAllister Street, San Francisco, CA 94102. SHS does not have a secure email through which to submit this form. I. PERSONAL INFORMATION. Please print or type. Last Name First Name Middle Initial Date of Birth Age Gender: M / F / NB Student ID# Telephone #: OK to leave message? / Preferred Name / Pronouns: Birthplace Email Emergency Contact Relationship (parent / spouse / friend) Emergency Contact Telephone # Emergency Contact Address Street City State Zip II. MEDICATIONS. List all prescription and over-the-counter medications, herbs, and vitamins you take on a regular basis. Name / Frequency Name / Frequency Name / Frequency III. ALLERGIES. List names of medicines or foods that have resulted in an unfavorable reaction. State reaction. Medications: Food or others, e.g., latex, insect bites, environmental: UC Hastings Student Health Services, 2/2019, Page 1 of 5
IV. MEDICAL HISTORY. Check the conditions you currently have or have had in the past. Indicate the year you first experienced symptoms/onset. Abnormal pap smear Acne (severe) Alcohol/substance abuse Allergies needing medication ADD/ADHD Anxiety or depression Asthma Bleeding disorder Blood clot in vein Cancer or tumor Chicken pox Diabetes Eating disorders Eczema or psoriasis Headaches (migraine) Heart disease Hepatitis Herpes simplex High blood pressure Intestinal disorder Mononucleosis Pneumonia/lung problems Pregnancy Psychological problems Seizures Sexually transmitted infection Smoker presently Thyroid disorder Tuberculosis or (+) test Ulcers Urinary tract disease ne of the above Other Please provide a brief explanation for the conditions you checked. Please list the type and date of any surgeries, hospitalizations, or serious injuries you have had. Please tell us if you have any health problems, including physical, mental, and emotional health, which require special arrangements. V. FAMILY HISTORY. Please indicate which, if any, blood relatives (parents, grandparents, siblings) have had the following diseases. Alcohol/drug abuse Asthma Bleeding disorder Blood clot in leg or lung Cancer Depression Diabetes Eating disorder Gynecologic problems High cholesterol Hypertension Intestinal disorder Kidney disease Mental illness Migraine headaches Neurological disorder Premature death Stroke Suicide attempt Thyroid disease Other UC Hastings Student Health Services, 2/2019, Page 2 of 5
VI. IMMUNIZATION REQUIREMENTS. The University of California (UC) is committed to protecting the health and well being of our students. Therefore, all of the UC campuses are implementing procedures to ensure that students are educated about and receive vaccinations to prevent potentially serious and contagious diseases.* Although many people receive the recommended vaccines, there are still documented outbreaks of vaccine preventable diseases in California each year amongst those who are not completely immunized. *Vaccination, Screening Requirements, and Recommendations are adopted from the California Department of Public Health (CDPH) IMMUN IZATION & SCREENING RECOMMENDATIONS FOR COLLEGE STUDENTS in place February 1, 2016. NOTE: Any revisions of the CDPH recommendations for colleges and universities as of February 1 each year will be reflected in UC requirements for the subsequent fall academic term. A. REQUIRED VACCINATIONS & SCREENING tice: All incoming UC students are REQUIRED to obtain the following vaccines and must submit a copy of their immunization or medical record, which provides proof of immunization to SHS. Failure to provide this information will result in a hold on your registration the following semester, which will prevent you from registering for classes. Please state the dates (MM/DD/YYYY) for your required vaccines or titers (laboratory evidence of immunity to disease) and tuberculosis screening (as appropriate) below. VACCINE OR SCREENING REQUIRED DOSE FIRST DOSE SECOND DOSE TITER LEVELS (if unable to provide vaccine records) Measles, Mumps and Rubella (MMR) Vaccine Varicella (chickenpox) Vaccine Two doses with first dose st on or after 1 birthday; OR positive titer Two doses with first dose on or after 1 st birthday; OR positive titer N/A if over age 21 135) Vaccine All incoming students must complete Section B. Tuberculosis Risk Assessment. Most recent test (MM/DD/YYYY): Result: UC Hastings Student Health Services, 2/2019, Page 3 of 5
B. TUBERCULOSIS RISK ASSESSMENT 1. Have you traveled or lived for more than a month in one of the following countries below with a high rate of tuberculosis (TB)? If yes, please check all countries with high rates of TB that apply. Afghanistan Congo DR Kenya New Caledonia Sudan Algeria Cote d Ivoire Kiribati Nicaragua Suriname Angola Croatia Korea-DPR Niger Syrian Arab Republic Anguilla Djibouti Korea-Republic Nigeria Swaziland Argentina Dominican Republic Kuwait Niue Taiwan Armenia Ecuador Kyrgyzstan N. Mariana Islands Tajikistan Azerbaijan Egypt Lao PDR Pakistan Tanzania-UR Bahamas El Salvador Latvia Palau Thailand Bahrain Equatorial Guinea Lesotho Panama Timor-Leste Bangladesh Eritrea Liberia Papua New Guinea Togo Belarus Estonia Lithuania Paraguay Tokelau Belize Ethiopia Macedonia-TFYR Peru Tonga Benin Fiji Madagascar Philippines Tunisia Bhutan French Polynesia Malawi Poland Turkey Bolivia Gabon Malaysia Portugal Turkmenistan Bosnia & Herzegovina Gambia Maldives Qatar Tuvalu Botswana Georgia Mali Romania Uganda Brazil Ghana Marshall Islands Russian Federation Ukraine Brunei Darussalam Guam Mauritania Rwanda Uruguay Bulgaria Guatemala Mauritius St. Vincent & The Grenadines Uzbekistan Burkina Faso Guinea Mexico Sao Tome & Principe Vanuatu Burundi Guinea-Bissau Micronesia Saudi Arabia Venezuela Cambodia Guyana Moldova-Rep. Senegal Viet Nam Cameroon Haiti Mongolia Seychelles Wallis & Futuna Islands Cape Verde Honduras Montenegro Sierra Leone W. Bank & Gaza Strip Central African Rep. India Morocco Singapore Yemen Chad Indonesia Mozambique Solomon Islands Zambia China Iran Myanmar Somalia Zimbabwe Colombia Iraq Namibia South Africa Comoros Japan Nauru Spain Congo Kazakhstan Nepal Sri Lanka 2. Were you born in a country with high rates of TB? 5. Have you had close contact with anyone who was sick with TB? 3. Have you been a resident or employee of high-risk congregate settings, e.g., correctional facility, long-term care facility, or homeless shelter? 4. Have you been a member of any of the following groups that may have increased risk of latent M. tuberculosis infection or active TB disease, e.g., medically underserved, low-income, or drug or alcohol abusers? 6. Have you been a volunteer or healthcare worker who served clients who have an increased risk for active TB disease? If you answered NO to all of the questions in Section B, no further testing or action is required. If you answered YES to one or more of the questions in Section B, you are required to receive TB testing and a healthcare provider must complete the attached Tuberculosis Screening Form. VII. CERTIFICATION I certify that to the best of my knowledge this information is complete and accurate. I have read and understand the immunization requirements for incoming students in Section VI above. I agree to submit a copy of my immunization record or medical records providing proof of immunization to SHS by mail, fax, or personal delivery. Student Signature Date UC Hastings Student Health Services, 2/2019, Page 4 of 5
STUDENT HEALTH SERVICES TUBERCULOSIS SCREENING FORM MUST BE COMPLETED BY HEALTH CARE PROVIDER If you are at risk for having Tuberculosis, you are required to receive further testing. You may choose to have a PPD test (Mantoux) or an Interferon Gamma Release Assay (IGRA). Either test must be completed within 12 months before entering UC Hastings. If you receive a positive finding on either test, you are required to have a chest x-ray. Once you have completed your tests, a licensed healthcare provider must complete the following information and sign this form. Name of Student 1. Please indicate the test the patient took. Date of Birth PPD (Mantoux) Test Interferon Gamma Release Assay (IGRA) 2. When did the patient take the test? (MM/DD/YYYY) 3. When were the results read? (MM/DD/YYYY) 4. If the patient took the PPD Test, please include the results of the patient s PPD Test in mm of induration: mm 5. If the patient took the IGRA test, please indicate the results. 6. If the patient s PPD Test result was positive (10mm or more) or the patient s IGRA is positive, the patient must have a chest x-ray. When did the patient have a chest x-ray? (MM/DD/YYYY) 7. Please indicate the results of the patient s chest x-ray. 8. If the patient s PPD Test was positive and the patient has been treated, please describe the treatment below. 9. Name of Health Care Provider Signature of Health Care Provider Signature Date UC Hastings Student Health Services, 2/2019, Page 5 of 5