Part I: Health Form This form is to be completed by the incoming student by July 15. Name: Date of Birth: Last First Middle MM/DD/YYYY Social Security #: Marital Status: ( ) Single ( ) Married ( ) Divorced Home Phone: Cell Phone: MBU Email: @marybaldwin.edu Parent/Guardian s Name: Parent/Guardian Home Phone: Cell Phone: Class Entering: ( ) Freshman ( ) Transfer Mailing Address: Street City State Zip In case of emergency, notify: Day/Work Phone: Home/Night Phone: Relationship:
PROOF OF HEALTH INSURANCE (SUBMIT A COPY OF YOUR VALID CARD) Insurance Company: Insurance Subscriber s Name: Insurance Policy Number: Insurance Company s Telephone Number: DISCLAIMER: IF OUT-OF-STATE INSURANCE, PLEASE VERIFY COVERAGE FOR VIRGINIA PERMISSION FOR TREATMENT The University reserves the right to have any student admitted to the University examined by the University Physician/Nurse Practitioner. This form must be signed by the student. If the student is a minor (under 18 years old), this form must also be signed by the parent or legal guardian so that the appropriate diagnosis and treatment may be promptly carried out. I certify that the information provided is true and complete to the best of my knowledge. I also understand that the information I have provided in the health record will be reviewed by the Health Center, Counseling and Psychological Services, and Head Athletic Trainer (*if applicable). I give permission to the University to furnish such procedures as may be deemed necessary by the Health Center staff, Counseling and Psychological Services staff, and the Health Athletic Trainer (if applicable) on my student s behalf. Student Signature: Date: Parent/Guardian Signature: Relationship:
PERSONAL HEALTH HISTORY Please circle to indicate if you have ever been or are now being treated for the following: ADD/ADHD FRACTURE AIDS/HIV HEART CONDITION ALCOHOLISM HEPATITIS/LIVER DISEASE ALLERGIES/HAY FEVER HERPES ANEMIA HYPERTENSION (HIGH BLOOD PRESSURE) ANXIETY HYOGLYCEMIA (LOW BLOOD SUGAR) ASTHMA IRRITABLE BOWEL SYNDROME BLOOD DISORDERS MIGRAINE HEADACHES CANCER MONONUCELOSIS CEREBAL PALSY MULTIPLE SCLEROSIS CYSTIC FIBROSIS ORGAN TRANSPLANT CHRONIC BRONCHITIS PELVIC INFECTION CHRONIC KIDNEY CONDITION PHLEBITIS CHRONIC INFLAM. BOWEL DISEASE RHEUMATIC FEVER CROHN S DISEASE RHEUMATOID ARTHRITIS DENTAL DISEASE SEIZURE DISORDER DERMATOLOGICAL DISORDERS SEXUALLY TRANSMITTED DISEASE DEPRESSION STOMACH PROBLEMS/PEPTIC ULCER DIABETES THYROID DISORDER DRUG DEPENDENCY TUBERCULOSIS DYSMENORRHEA URINARY TRACT INFECTION EATING DISORDER OTHER: Give details regarding any condition you marked above:
FAMILY HISTORY Please circle to indicate if the condition exists in your family (parents, siblings, and grandparents): ASTHMA HIGH BLOOD PRESSURE BLEEDING/CLOTTING DISORDERS MENTAL ILLNESS CANCER RESPIRATORY PROBLEMS DIABETES RHEUMATIC FEVER EYE DISORDERS STROKE HEART DISEASE TUBERCULOSIS OTHER: ADDITIONAL INFORMATION Answer the following questions: Allergies: Medications, Foods, Environmental, Seasonal, etc. (Please list): Hospitalizations: Yes No (if yes, please provide details) Surgeries: Yes No (if yes, please provide details) Medications: Yes No (if yes, please list drug name and dosage currently taken)
Do you have a medical condition which may interfere with eating in the university dining hall (special diets cannot be supplied)? No Yes (if yes, please specify) MENTAL HEALTH INTERVENTIONS Have you ever had any treatment or counseling for any emotional, behavioral, or psychological condition? Yes No Have you ever been treated with any medication for psychiatric reasons? Yes No If the answer to any of the above questions is yes: A full report from your physician, psychiatrist, certified therapist, or counselor is required. The full report will include a statement of the diagnosis, treatment, response to treatment, and need for follow up. This report should be directed to the college Health Center, Head Athletic Trainer (if applicable), and Counseling and Psychological Services. This report will not be released without the written consent of the student. SPECIAL NEEDS Do you consider yourself handicapped or disabled in any way that requires you to receive special consideration from the university? Yes No If so, please give details below: The Health Center works in cooperation with the Office of Student Life in attempting to meet the needs of students with special needs. Would you object if the Heath Center referred your name to: Office of Student Life? Yes Accessibility Services Coordinator? No Yes No
Part II: Health Care Provider Evaluation The following information is required from your Health Care Provider for medical clearance into Mary Baldwin University. Please make an appointment with your provider and bring a printed copy of this form for completion and signature. Student s Name: Date of Birth: Last First Middle MM/DD/YYYY PHYSICAL EXAMINATION Height: Weight: Blood Pressure: Respirations: Pulse: Lymph Nodes: Vision Corrected (L): (R): (BOTH): Uncorrected (L): (R): (BOTH): Area Examined : Normal: Abnormal Findings: (please explain) Lungs/Chest Heart Pulses SKM Eyes/Ears/Nose/Mouth/Throat Abdomen Musculoskeletal Neck Shoulders Elbows Wrists/Hands Back Knees Ankles/Feet Reflexes Other
IMMUNIZATION RECORD PUBLIC HEALTH REQUIREMENTS Virginia Code (Sec 23-7.5) requires students attending Mary Baldwin University to provide documentation of their immunizations by a licensed health professional. All information must be documented in the English language. Student s Name: Date of Birth: Last First Middle MM/DD/YY REQUIRED M.M.R. (Measles, Mumps, and Rubella) Two doses required. Dose #1 given at age 12-15 months or later Date Given: Dose #2 given at age 4-6 years or later and at least one month after Dose #1 Date Given: TETANUS-DIPHTHERIA Primary series with DtaP or DTP and booster with Td in the last ten years meets requirement refer to ACIP for details Primary series of four doses with DtaP or DTP Date series completed: Tetanus-Diptheria (TD) booster within the last ten years Date Given: POLIO Primary series in childhood meets requirement, three primary series schedules are acceptable refer to ACIP for details Date series completed: VARICELLA History of chicken pox or two doses of vaccine? ( ) No ( ) Yes, given at age Immunization Dose #1 Date: Dose #2 Date: (given at least one month after Dose #1 if age 13 years or older) MENINGOCOCCAL One dose prior to entry into college (or a booster done at age 16 years or older, first dose given earlier) for students living in residence halls to reduce their risk of contracting meningitis. Quadrivalent polysaccharide vaccine Date given: HEPATITIS B Three doses of the vaccine are required to complete series. Dose #1 Date: Dose #2 Date: Dose #3 Date: TUBERCULOSIS SCREENING PPD required regardless of prior BCG inoculation. PPD (Mantoux) within the past 12 months (tine or monovac not acceptable) Date Given: Date Read: Result: Neg Pos If positive, mm induration (horizontal diameter) If PPD is positive, chest x-ray required. Date: Results: Normal Abnormal HIGHLY RECOMMENDED INFLUENZA Annual immunization in Fall is recommended to avoid disruption to academic activities. Date vaccinated:
HEALTH CARE PROVIDER CERTIFICATION Physician Signature: Date: Printed Name: Phone: Address: Fax:
ADDITIONAL EVALUATION (FOR ATHLETICS AND VWIL CADETS ONLY) Participation Status for Athletics/VWIL cadets Physical Training Cleared with no restriction Not cleared for the following activities: Due to: Physician Signature: Date: Note for athletes: A physical exam and additional forms are required. You may download and print them at marybaldwinathletics.com/information/athletictraining/forms. (This is not required for VWIL cadets.)