1584 Wesleyan Drive FORM A Norfolk, VA Phone: (757) Health History immunization & Physical Form

Transcription

1 Mail completed form to: Marlin Health Services 1584 Wesleyan Drive FORM A Norfolk, VA Phone: (757) Health History immunization & Physical Form Virginia State law (code ) requires all students to submit a completed Health History and Immunization record. All students must have primary insurance coverage through their own insurance provider OR accept the policy offered by the VWC Business office. Please attach a copy of the front and back of your insurance card for Health Services. Dear VWC Student: Virginia Wesleyan College would like to take this opportunity to welcome you to VWC. We look forward to an exciting year. We understand that this is a busy time for new and returning college students; however, the following Health Form paperwork must be completed before the school year begins. Please schedule an appointment with your doctor for your admission health evaluation and/or your athletic physical soon. ALL STUDENT ATHLETES at Virginia Wesleyan College must complete Form A (for Health Services) and the electronic medical records (for Athletics department). Instructions and electronic medical records can be found on the athletic training website at Please note that NCAA guidelines now require Sickle Cell and Trait testing. All RESIDENT STUDENTS at Virginia Wesleyan College must complete the entire Health form (Sections A-D). Mail these documents to the Office of Health Services and maintain a copy for your personal records. ALL STUDENTS at Virginia Wesleyan College must complete Sections A, B &D. The Medical Examination (Section D) is highly recommended; however, it is not required. Mail these documents directly to the Marlin Health Services office and maintain a copy for your personal records. The deadline for return in the Fall is August 1st The deadline for return in the Spring is January 2 nd Section A- Emergency Contact Consent and Insurance Information Section B- Medical History Section C- Medical Examination Section D- Immunization and waiver form *Attach a copy of the front and back of insurance card* Mail forms to: Virginia Wesleyan College Marlin Health Services 1584 Wesleyan Drive Norfolk, VA (757) Thank you, Valerie Covington, RN, BSN Director of Health Services

2 Section A EMERGENCY CONTACT CONSENT AND INSURANCE INFORMATION Admission Status: ( ) Freshman ( ) Transfer ( ) Returning Student ( ) Living on campus ( ) Living off campus CONFIDENTIAL Social Security Number: Birth date: Last Name: First: Middle Sex: Age: Home address: City State: Zip Local Address: City State: Zip: Personal Cell Phone Number: Emergency Contact: Name Relationship Phone# Family Physician: Phone # Insurance Information: Name of Insured Insurance Co. Policy # Phone# I certify that the above information is correct. I give permission to Virginia Wesleyan College or its representative(s) to (1) secure health care services which may include transportation to a health care provider and/or to a hospital in case of a serious emergent illness or injury, physical examination, injections, treatments and diagnostics. (2) To release health information to persons who have legitimate need to know as defined by state and federal regulations. Student signature Student Printed name Parent/Legal Guardian for Student under Age 18 Signature: Printed Name: Detailed Information Current Medications/ steroids/herbals/dosage Drug /food Allergies/ Type of reaction Epi- pen/ Medic bracelet? Hospitalizations /dates

3 Section B Medical History Name: Date of Birth: Have you had or are now experiencing any of the following? If yes, note the date of occurrence if known: Yes No Date Yes No Date Head/ Neurological Gastrointestinal Frequent headaches/migraines Abdominal Pain (severe/recurrent) Dizziness or fainting Ulcer Loss of consciousness Constipation Head injuries Blood in stool Neck/spine/back injury Hepatitis A,B,C Hernia Eyes/ Ears/ Nose/ Throat Musculoskeletal Vision or eye problems Swollen or painful joints or extremities Tonsil/Adenoid removal Chronic or severe back problems Allergies or hay fever Lumps in armpit or groin Ear or hearing problems Chronic Diseases Sinusitis/ Strep Diabetes mellitus Dental problems or TMJ Asthma Skin High Blood Pressure Severe acne or skin disorder Arthritis New or changing moles Sickle cell disease Blood Disorder Seizures or epilepsy Anemia/Sickle Cell Thyroid disease Bleeding disorder Elevated Cholesterol Enlarged glands /lymph nodes Genitourinary Heart/ Circulation/ Chest Urinary or kidney problems Severe chest pain or pressure Additional medical history Heart disease or murmur Cancer Rapid irregular pulse Unusual fatigue (over 1 month) Myocarditis Recent gain or loss of weight Mononucleosis (over 10 pounds) Blood Clots or vein problems Eating disorder Family member with heart attack Female Or death before age 50 absent or irregular periods Respiratory Disabling cramps w/ period Chronic cough (over 1 month) Diet Pneumonia Special diet for medical reasons Tuberculosis or positive PPD Mental Health Shortness of breath OCD Wheezing Depression Tobacco Use: Schizophrenia Chew tobacco Bipolar Smoke Asperger s Syndrome ADHD or ADD Other:

4 Section C PHYSICAL EXAMINATION Name: **REQUIERED FOR ALL RESIDENT AND FULL TIME STUDENTS / RECOMMENDED FOR ALL STUDENTS** ALL OF THE FOLOWING INFORMATION MUST BE COMPLETED BY A PHYSICIAN, NURSE PRACTITIONER OR PHYSICIAN ASSISTANT Vital Signs Pulse Blood Pressure Height Weight Vision Screening: Right 20/ Corrected to 20/ Left 20/ Corrected to 20/ Laboratory (if indicated): According to NCAA guidelines, all student athletes must have Sickle Cell and Trait testing done prior to participation in sports activities. Please see VWC Athletic website for waiver if waiver is requested. Results Results Results CBC Urinalysis Other Serology *Sickle Cell - date: Other Results: SYSTEMS General Appearance FINDINGS HEENT Cardiovascular Lungs Breast Abdomen Genitalia Musculoskeletal Spine Skin & Lymphatic Neurological SUMMARY OR ASSESSMENT AND DIAGNOSIS: RECOMMENDATIONS: TYPED OR PRINTED NAME OF PROVIDER SIGNATURE DATE

5 Section D **Required Immunizations** TO BE COMPLETED BY MEDICAL PERSONNEL OR ATTACH A COPY OF SHOT RECORD Name Date of Birth A. Measles, Mumps and Rubella: Individuals born before 1957 are considered immune. Date of Birth: MMR#1 MMR#2 Titer indicating immunity: (attach a copy) Level/Value: B. Tetanus Diphtheria or Tdap *Last booster must be within the past10 years TD, DT: TDap C. Polio (OPV or IPV): Completion of primary series in childhood Yes No Last booster D. PPD / Tuberculosis test Date of TB Screening: Is TB test recommended? Yes No Date of test: Results: Negative Positive (size) mm Chest X-Ray Results: Negative Positive Treatment /Medication recommended? Yes No Medication Prescribed: Duration: E. Hepatitis B or Waiver Hepatitis B #1 Hepatitis B #2 Hepatitis B #3 Titer indicating immunity: (attach a copy) Level/ Value: Signed Hepatitis B Waiver F. Meningococcal Vaccine or Waiver Meningococcal Vaccination Menactra Vaccination Signed Meningitis waiver Date Date G. Varicella Vaccine (chicken pox) Has had disease as child? Yes No Varicella Dose# 1 Varicella Dose # 2 Titer indicating immunity (attach a copy) Level/Value: Provider (printed) Name & Title Address or Office Stamp and phone number: Provider Signature Virginia Wesleyan College Health Services MENINGOCOCCAL and Hepatitis B VACCINE WAIVER I have read the information provided about meningococcal meningitis and Hepatitis B and understand the risks of the disease; however, I choose not to receive the vaccine. I understand that in the event of an outbreak, unvaccinated students will be at increased risk for contracting the illness. Information can be found on the following website: Student s Printed Name: Birth Student Signature As a parent or other legal representative, I choose not to have the student named above vaccinated against Meningococcal and Hepatitis B disease. Parent/Guardian Printed Name: Signature of Parent/Guardian Date