Agnes Scott College Student Health Services 141 East College Avenue Decatur, GA Phone: (404) Fax: (404)

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1 1 The Entrance Health Record is required for enrollment at Agnes Scott College. The deadline for the submission is June 1 st for the fall semester and December 1 st for the spring semester. Students may not register for classes until forms are submitted and complete. Please return the completed forms to: Agnes Scott College Student Health Services 141 East College Avenue Decatur, GA Phone: (404) Fax: (404) Full Name: Date of Birth: Last First Middle yy College ID Number: Permanent Address: ( ) Street City State/Country Zip Phone Name of Parent(s), Spouse, or Guardian: Relationship: Work Phone: Home Phone: Cell Phone:_ Person to notify in an emergency: 1. Name: Relationship: Address: Street City State/Country Zip Work Phone: Home Phone Cell Phone: Permission for diagnostic and treatment procedures: I hereby authorize healthcare providers at Agnes Scott College Student Health Center, their agents or consultants to perform diagnostic and treatment procedures, which in their judgment may become necessary while enrolled as a student at Agnes Scott College. Student Signature (Required) Date yy Parent or Guardian* Date yy (*Required if student is not 18 years old)

2 Name: 2 Physician/ Provider Summary To be completed by the physician/provider NOT a family member BP P Height Weight Nor mal Abnormal HEENT Skin Heart Lungs Abdomen Musculoskeletal Neurological Comments: Assessment: If the student is under a treatment program that you would like to continue, please enclose pertinent medical history and recommendations. REQUIRED Does student have any allergy to foods or drugs? If so, list: May student participate in competitive athletic programs? Is this student under any form of medical or psychiatric treatment and/or prescription medication? If so, list: Has the student ever had an eating disorder? If yes, please explain: Are there any special accommodations needed? If yes, please explain: Please list hospitalizations/surgery dates: M.D./D.O./N.P./P.A. S Name (please print): Signature: May not be signed by a family member. Address: Date of Exam: Telephone Number: ( ) M.D. D.O. N.P. P.A

3 3 Name: REQUIRED Record of Immunizations/Tests (This form must be completed and signed by your healthcare provider) Georgia s law and/or Agnes Scott College require the following immunizations or titer test for all entering students. You will not be able to register for classes until this information has been provided. You must include the month, day, and year, and this form must be signed and dated by a M.D., D.O., N.P., or P.A. TETANUS/DIPTHERIA/PERTUSSIS Completed primary series of four doses (DTaP or DTP) Td or Tdap booster (circle which vaccine used) within the last 10 years (Tdap recommended for ages unless contra indicated) POLIO Date: / / yy / / yy Primary series of four doses (OPV/IPV or combination last dose after age 4) Date: / / yy MEASLES, MUMPS, RUBELLA DOCUMENTATION Two doses each of measles and mumps, and one dose of rubella are required as trivalent or monovalent vaccine. The first dose must be given on or after age 12 months, the second must be at least one month later. Or laboratory evidence of immunity (positive titer). Applies to all US students born after M.M.R first dose / / second dose / / or date of titer / / Titer result (attach copy of MEASLES first dose / / second dose / / or date of titer / / Titer result MUMPS first dose / / second dose / / or date of titer / / Titer result RUBELLA first dose / / or date of titer / / Titer result OR (attach copy of (attach copy of (attach copy of HEPATITIS B (three doses or positive Hepatitis B surface antibody titers) Date / /, / /, / /, dosage mcg or ANTHBS date / / Titer result (attach copy of

4 Name: 4 MENINGOCOCCAL VACCINE (required by the Georgia Department of Public Health.) **If first vaccine was prior to the 16 th birth date a booster is required.** Quadrivalent Conjugate Vaccine, MCV4 (Menactra/Menveo First dose / / Booster / / Preferred) OR Quadrivalent Polysaccharide Vaccine, MPSV4 (Menomune acceptable alternative) First dose / / Booster / / VARICELLA (History of chicken pox disease, or birth in the US before 1980,or positive varicella antibody, or two doses of vaccine) History of disease: Born in US prior to 1980: Varicella antibody / / reactive non-reactive (attach copy of Immunization first date : / / second dose / / (given at least 12 weeks after 1 st dose for age 1 12 years and at least 4 weeks after 1 st dose if age 13 years or older) Optional Vaccines (Please list clearly other immunizations you have received.) HPV Vaccine / /, / /, / / mm/dd/yr Hepatitis A / / booster dose 6-12 months later / / M.D./D.O./N.P./P.A. signature: Date: (Required May not be signed by a family member)

5 Name:_ TUBERCULOSIS SCREENING (Required) Please answer the following: Have you ever had a positive TB Test? Have you ever had close contact with anyone who was sick with TB? Were you born in one of the countries listed below and arrived in the US within the past 5 years?* (If yes, please CIRCLE the country) Have you ever traveled** to/in one or more of the countries listed below? If yes, please CHECK the country/ies) *future CDC updates may eliminate the 5 year time frame **The significance of the travel exposure should be discussed with a health care provider and evaluated. Afghanistan Algeria Angola Anguilla Argentina Armenia Azerbaijan Bahamas Bahrain Bangladesh Belarus Belize Benin Bhutan Bosnia & Herzegovina Botswana Brazil Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Central African Rep. Chad China Colombia Comoros Congo Congo DR Cote d Ivoire Croatia Djibouti Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji French Polynesia Gabon Gambia Georgia Ghana Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras India Indonesia Iran Iraq Japan Kazakhstan Kenya Kiribati Korea-DPR Korea-Republic Kuwait Kyrgyzstan Lao PDR Latvia Lesotho Liberia Lithuania Macedonia-TFYR Madagascar Malawi Malaysia Maldives Mali Marshall Island Mauritania Mauritius Mexico Micronesia Moldova-Rep. Mongolia Montenegro Morocco Mozambique Myanmar Namibia Nauru Nepal New Caledonia Nicaragua Niger Nigeria Niue N. Mariana Islands Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russian Federation Rwanda St. Vincent & the Grenadines São Tomé & Príncipe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Swaziland Syrian Arab Republic Tajikistan Tanzania-UR Thailand Timor-Leste Togo Tokelau Tonga Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Wallis & Futuna Islands West Bank & Gaza Strip Yemen Zimbabwe Source: World Health Organization Global Tuberculosis Control, WHO Report 2006, Countries with Tuberculosis incidence rates of > 20 cases per 100,00 population. For future updates, reference If the answer is YES to any of the above questions, the Medical Evaluation Form for Tuberculosis (see next page) to have a Tuberculin Skin Test/PPD (TST) or Interferon Gamma Release Assay (GRA) within 3 months prior to enrollment in classes, unless a previous positive test has been documented. If the answer to all of the above questions is NO, no further testing or further action is required. Student Signature Date M.D./D.O./N.P./P.A. Signature Required Date May not be signed by a family member

6 6 Name: TUBERCULOSIS (TB) MEDICAL EVALUATION If the answer to any of the questions on the Screening Form was yes, you are required to complete this page. 1. Does the student have signs of active tuberculosis disease? If No, proceed to 2a or 2b below. If Yes, proceed with additional evaluation to exclude active tuberculosis disease including tuberculosis skin testing, chest x-ray, and sputum evaluation as indicated. 2a. Tuberculin Skin Test/PPD (TST) Must be administered in the United States. The TST interpretation is based on the mm of indication as well as risk factors Date given / / Date read / / Result mm of induration, transverse diameter (If no induration, mark 0 ) Interpretation: positive negative Interpretation of Tuberculin Skin Test guidelines Risk Factor Close contact with an individual with infectious TB Positive Result 5mm or more Born in a country that has a high rate of tuberculosis Traveled or lived for one month or more in a country that has a high rate of tuberculosis None (test not recommended) 10mm or more 10mm or more 15mm or more OR 2b. Interferon Gamma Release Assay (IGRA) Attach copy of lab result Date obtained / / (specify method) QFT-G QFT-FIT other Result: Negative Positive Intermediate 3. Chest x-ray: (Required within the last 3 months prior to enrollment classes, if TST or IGRA is positive) Must provide a copy of results. Date of chest x-ray / / Result: normal abnormal Treatment (required for active tuberculosis, recommended for latent tuberculosis infection) Yes DRUG, DOSE, FREQUENCY AND DATES No M.D./D.O/N.P./P.A. signature (Required may not be signed by a family member) Date

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