FLORIDA MEMORIAL UNIVERSITY Student Health Services

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1 1 FLORIDA MEMORIAL UNIVERSITY Student Health Services STATEMENT OF HEALTH INSURANCE COVERAGE FORM Date Due: Office of Student Affairs Miami Gardens, FL Phone Fax Florida Memorial University provides supplemental health insurance coverage with limited benefits. Please do not cancel your private health insurance policy. Please submit a copy of your private health insurance along with your health records. Name Student ID # Home Address Phone Number Name of Insurance Company Address Phone Number Policy Number Expiration Date Copy of Personal Health Insurance Here

2 2 FLORIDA MEMORIAL UNIVERSITY Date Due: July All incoming new and transfer students are required to provide a current physical examination prior to registration. Physical Examination Form Academic Year: Office of Student Affairs Miami Gardens FL Phone Fax Undergraduate, Class of Graduate Student, School of Student ID # Last Name First Name Middle Name Date of Birth / / Month Day Year Cell Phone Gender: Male Female Home Address Emergency Contact Name Relationship Emergency Contact Phone Medical History No Pertinent History (Check all that apply) Asthma Back/ Neck injury Bleeding Disorder Concussion/head Injury Chronic cough Chest Pain Dizziness Depression Heart Murmur Irregular heartbeat Hypertension Hernia Headaches Hearing Problem Heat exhaustion Menstrual Problems Smoker Seizure Skin Infection STD Obesity Broken bones Kidney disease Sickle cell anemia Tuberculosis Surgery Stomach Problems Diabetes Alcohol Abuse Other Have you ever been medically disqualified from sports participation by a physician? Yes No If yes, Why? PHYSICAL EXAMINATION FORM: to be completed and signed by your healthcare provider Height Weight BMI Blood Pressure Pulse Temp Allergy Check: Medication Food Insect Environmental Other If yes to allergies, is an EpiPen prescribed? Yes No Current or past medical, surgical, or psychiatric condition(s) requiring on-going care Please include relevant medical information Current Prescription Medications: Yes No If yes, write the Name(s) Dose Frequency Reason

3 3 Revised 4/2011(vr) PHYSICAL EXAMINATION (continued) Page 2 NAME ID # DOB Clinical Evaluation Normal Abnormal Comments General appearance Skin Mouth, teeth, gums Neck and Thyroid Lungs / Chest Lymph Nodes Heart Abdomen Genitalia Back / Spine / Musculoskeletal Ortho / Spine / Extremities Pulses Radial Femora Pedal Neurological EKG for Athletic Participation Other findings I have reviewed the medical history and examined this student. The information is accurate and complete to the best of my knowledge. This student is cleared / not cleared for full participation in intramural and collegiate sports activity. Yes / Unlimited Activity and fit for College No/ Limited activity Reason Recommendation Signature of Healthcare Provider Date Phone Print Name of Healthcare Provider Address Fax # Official Stamp Revised 4/2011(vr)

4 4 Name FLORIDA MEMORIAL UNIVERSITY Office of Student Affairs IMMUNIZATION DOCUMENTATION Academic Year Student ID # Date Due Student Health Services Florida Memorial University Miami Gardens FL Phone: Fax: All incoming students born after December 31, 1956 are required to present a copy of their immunization records to the University before registration can be completed. If the doctor completing your physical examination does not have your immunization records, please submit a copy of your original records. All transcribed immunization documents MUST be signed and by a medical provider and officially stamped or notarized. A hold status will be assigned to your registration status if your immunization forms are not submitted or completed. Documents written in a foreign language must be translated in English before submission Acceptable immunization records include: - High school records - Health Department records - Physician s or Military records - Personal official records signed, stamped and dated by a qualified healthcare provider - Previous college/university records (Ask for records to be transferred ) VACCINE Dose 1 Month/ Day/ Year Dose 2 Month/Day/ Year Dose 3 Dose 4 Dose 5 Comment DTP OR DTaP TD To be less than 10 years old MMR(Combined) OR MMR (Separate) Measles(dose 1) Measles (Dose 2) Mumps Rubella HEPATITIS B PPD CXR result Less than 3 months prior to registration If PPD was Positive MENINGITIS Optional. If no, Please sign and return declination form OTHER

5 5 FLORIDA MEMORIAL UNIVERSITY Office of Student Affairs MENINGITIS INFORMATION / DECLINATION FORM PLEASE READ, Sign and Return if necessary Meningitis is an infection of the fluid of a person's spinal cord and the fluid that surrounds the brain and is usually caused by a viral or bacterial infection. Knowing whether meningitis is caused by a virus or bacterium is important because the severity of illness and the treatment differ. Viral meningitis is generally less severe and resolves without specific treatment. Bacterial meningitis can be quite severe and may result in brain damage, hearing loss, learning disability or death. For bacterial meningitis, it is also important to know which type of bacteria is causing the meningitis because antibiotics can prevent some types from spreading and infecting other people. Signs and symptoms: High fever, headache, and stiff neck are common symptoms and can develop over several hours or 1 to 2 days. Other symptoms may include nausea, vomiting, discomfort looking into bright lights, confusion, and sleepiness. As the disease progresses, patients of any age may have seizures. Diagnosis: The diagnosis is usually made by growing bacteria from a sample of spinal fluid. Identification of the type of bacteria responsible is important for selection of correct antibiotics. Can meningitis be treated? Yes. Bacterial meningitis can be treated with a number of effective antibiotics. It is important, however, that treatment be started early in the course of the disease. Is meningitis contagious? Yes, some forms of bacterial meningitis are contagious. The bacteria are spread through the exchange of respiratory and throat secretions (i.e., coughing, kissing). Sometimes the bacteria that cause meningitis spread to other people who have had close or prolonged contact with a patient with meningitis caused by Neisseria meningitides. People in the same household or day-care center, or anyone with direct contact with a patient's oral secretions (such as a boyfriend or girlfriend) would be considered at increased risk of acquiring the infection. Are there vaccines against meningitis? Yes, there are two vaccines against N. meningitidis available in the U.S. (1) Meningococcal polysaccharide vaccine (MPSV4 or Menomune ) (2) Meningococcal conjugate vaccine (MCV4 or MenactraT) Meningitis cases should be reported to state or local health departments to assure follow-up care of close contacts and recognize outbreaks. All Residential students are recommended to receive this vaccine prior to the first semester registration. If you decide not to be vaccinated, please sign this document and return it with your health package. DECLINATION FORM: This is to certify that I have read and understand the information written above and have decided that I will not receive the meningitis vaccine at this time. Please sign and date: Date Student ID # Date Parent s Signature and notarization if you are a minor

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