UNIVERSITY OF MOUNT UNION HEALTH RECORD

Transcription

1 UNIVERSITY OF MOUNT UNION HEALTH RECORD Name Scial Security # Address LAST FIRST MIDDLE ADDRESS CITY STATE ZIP CODE Date f Birth M F Cuntry f Birth Student Cell Phne Persn t Ntify in an Emergency Address f Abve (Relatinship) Hme Phne Wrk Phne Cell Phne TUBERCULOSIS DIABETES HIGH BLOOD PRESSURE/STROKE HEART TROUBLE CANCER YES NO RELATIONSHIP FAMILY HEALTH HISTORY YES NO RELATIONSHIP ASTHMA, HAY FEVER, HIVES EPILEPSY OR CONVULSIONS NERVOUS OR MENTAL DISORDER BLEEDING/CLOTTING DISORDER OTHER PERSONAL HEALTH HISTORY Have yu ever had r d yu nw have any f the fllwing (In lines f multiple statements, crss ut the inapplicable wrds.): Explain all answers belw. Yes N Yes N Yes BLOOD DISORDER MIGRAINE HEADACHE DIABETES TOBACCO USE HEPATITIS/ JAUNDICE EMOTIONAL/MENTAL PROBLEMS ORTHOPEDIC PROBLEMS MUMPS SEIZURES/CONVULSIONS SURGERY HIGH BLOOD PRESSURE ALCOHOL/DRUG ABUSE HIV KIDNEY/BLADDER TUBERCULOSIS ADHD/ADD ASTHMA RHEUMATIC FEVER HEART PROBLEMS SKIN PROBLEMS ALLERGIES/HAY FEVER ARTHRITIS THYROID PROBLEMS STOMACH OR BOWEL PROBLEMS If yes, r any ther medical cnditins r physical limitatins, give details N Check Each Item Yes N If yes, list: D yu take medicatin? Are yu allergic t any medicatins r latex? STATEMENT OF AUTHORIZATION Authrizatin is hereby granted, fr the health and welfare f the student, fr the University Physician t admit him/her t the hspital if necessary, and t refer this student t any duly licensed physician r surgen when indicated. Permissin is given t administer any medicatin, treatment, vaccines, etc., deemed necessary by the University Health Center staff. Are yu allergic t any fds? Signature f Student Date Signature f Parent/Guardian (if student is under 18 years f age) Date 1

2 Student UNIVERSITY OF MOUNT UNION HEALTH RECORD Scial Security Number Date f Birth Please indicate what insurance cverage yu have: Student insurance Available thrugh the University f Munt Unin Private insurance thrugh a parent/spuse Please cmplete the infrmatin belw Bth student insurance and private insurance Please cmplete the infrmatin belw Primary Insurance: Name f insured DOB Phne Relatinship f insured t student Emplyer Insurance Cmpany Insurance Cmpany Phne Plicy N. Secndary Insurance: Grup N. Name f insured DOB Phne Relatinship f insured t student Emplyer City State Zip Insurance Cmpany Insurance Cmpany Phne Plicy N. Grup N 2

3 UNIVERSITY OF MOUNT UNION HEALTH RECORD Name Date f Birth A. Tuberculsis Risk Assessment 1. Have yu had recent clse cntact with smene wh has infectius TB? 2. Were yu brn in, r have yu recently traveled t an area with a highprevalence f TB? (Africa, Asia, Eastern Eurpe r Central Suth America) *A full list f cuntries is available at 3. Have yu had an abnrmal chest x-ray suggesting inactive r past TB disease? 4. Histry f BCG Vaccine 5. Histry f psitive TB Test 6. Are yu a resident (r recent resident), emplyee r vlunteer in a high-risk cngregate setting (E.G., Crrectinal facilities, nursing hmes, hmeless shelters, hspitals, r ther healthcare facilities)? YES YES YES YES YES YES NO NO NO NO NO NO If the questins abve are all NO, n TB test is necessary (skip t page 4). If yu answered YES t any ne f the abve questins, yu will need t btain a TB test frm yur healthcare prvider r lcal health department. Please have the test and results dcumented belw: B. Tuberculin Skin Test (TST) (*Only required if YES t any questin abve) TST result shuld be recrded as actual millimeters (MM) f induratin, transverse diameter; if n induratin write 0. The TST interpretatin shuld be based n MM f induratin as well as risk factrs. Date Mantux (TST) Given: Date Read: Result: MM f Induratin Interpretatin: Psitive Negative Signature: Phne: C. Chest X-Ray (required if TST is psitive) Date f CXR Result: Nrmal Abnrmal 3

4 Name MANDATORY IMMUNIZATIONS REQUIRED BY THE UNIVERSITY OF MOUNT UNION A. M.M.R. (Measles, Mumps, Rubella) (Tw dses required at least 28 days apart.) Dse #1 / Dse #2 / B. Tetanus-Diphtheria-Pertussis 1. Primary series cmpleted? Yes N Date f last dse in series / 2. Date f mst recent bster dse must be within 10 years / Type f bster: Td Tdap (Preferred) Tdap bster recmmended fr ages unless cntraindicated HIGHLY RECOMMENDED IMMUNIZATIONS - (Refer t fr recmmendatins) C. Pli (Primary series, dses at least 28 days apart. Any f the three primary series are acceptable. See ACIP website fr details). 1. OPV alne (ral Sabin three dses): #1 / #2 / #3 / 2. IPV/OPV sequential: IPV #1 / IPV #2 / OPV #3 / OPV #4 / 3. IPV alne (injected Salk fur dses):.... #1 / #2 / #3 / #4 / D. Pneumcccal Plysaccharide Vaccine (One dse fr members f high-risk grups.) Date / E. Influenza (Annually) Date / F. Varicella (Birth in the U.S. befre 1980, a histry f chicken px, a psitive Varicella antibdy, r tw dses f vaccine meets the requirement.) 1. Immunizatin Dse #1 / Dse #2 / (Given at least 12 weeks after first dse ages 1-12 years and at least 4 weeks after first dse if age 13 years r lder) 2. Histry f Disease Yes N OR Birth in U.S. befre 1980 Yes N 3. Varicella antibdy / Result: Reactive Nn-reactive 4

5 Name G. Hepatitis B* (Three dses f vaccine r tw dses f adult vaccine in adlescents years f age, r a psitive hepatitis B surface antibdy meets the requirement.) 1. Immunizatin Dse #1 / Dse #2 / Dse #3 / Adult frmulatin Adult frmulatin Adult frmulatin Child frmulatin Child frmulatin Child frmulatin 2. Hepatitis B surface antibdy Date / Result: Reactive Nn-reactive H. Hepatitis A 1. Immunizatin Dse #1 / Dse #2 / I. Hepatitis A & B Cmbined Vaccine Dse #1 / Dse #2 / Dse #3 / J. Meningcccal Vaccine (At least ne dse at age 16 r greater) Quadrivalent cnjugate (preferred; administer simultaneusly with Tdap if pssible): Dse #1 / Dse #2 / Quadrivalent plysaccharide (acceptable alternative if cnjugate nt available) Meningcccal B Dse #1 / Dse #2 / K. Human Papillmavirus Vaccine (Tw dses if series started befre age 15 - three dses fr thse starting series after 15th birthday r HPV9) Date / (indicate which preparatin) Quadrivalent (HPV4) OR Bivalent (HPV2) Dse #1 / Dse #2 / Dse #3 / Infrmatin Needed fr the Office f Residence Life *In rder t cmply with an Ohi law, which went int effect July 1, 2005, any student planning n living n campus must be infrmed f the risk assciated with and the benefits f vaccinatin fr meningitis and hepatitis B. In accrdance with this law, we are prviding yu with the link t the Ohi Department f Health website ( fr further infrmatin. Please nt that this law des nt require vaccinatin, nr des it require the institutin t prvide r pay fr these vaccines. It requires nly disclsure f whether r nt yu have been vaccinated. Yur signature belw will suffice as a release fr the Health Center t be able t share the infrmatin regarding nly thse immunizatins with the Office f Residence Life, shuld the need arise. (signature and date) Immunizatin frms adapted frm the American Cllege Health Assciatin 5