STUDENT HEALTH CENTER VILLANOVA UNIVERSITY CHECK LIST
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1 CHECK LIST This health record must be COMPLETELY filled out and submitted to the Student Health Center by July 2nd. All students must submit a copy of this health record to the Student Health Center even if he/she is required to submit his/her health record to the Athletic Department, the Nursing School or ROTC. Please make two additional copies of your health record forms: One for your records at home and one for you to keep in your possession at school in the event you participate in intramural or club sport activities. DO NOT SEND THE TWO ADDITIONAL COPIES TO THE STUDENT HEALTH CENTER Completed Health Record: Medical History, Medications, Allergies. Required immunizations documented on Villanova Health Record. NO ATTACHMENTS Tuberculosis screening: (PPD/Mantoux) date and results (within the last 365 days) OR Quantiferon Gold TB test date required. A second meningitis vaccination is required if you received your first shot before the age of 16. Documented physical exam within 365 days prior to the start of incoming freshmen orientation. Two additional copies of the Student Health Record. One for your records at home and one for you to keep in your possession at school. Bring a copy of your insurance card to school in case of an emergency requiring hospitalization, x-ray, etc. PLEASE SEND THE HEALTH RECORD IN AS ONE COMPLETE PACKET. FAILURE TO SUBMIT A COMPLETED HEALTH RECORD TO THE HEALTH CENTER WILL RESULT IN THE INABILITY OF THE STUDENT TO REGISTER FOR SECOND SEMESTER CLASSES. 1
2 CONFIDENTIAL 800 Lancaster Avenue Villanova, PA Phone: (610) Fax: (610) **COMPLETED FORMS DUE BACK TO THE HEALTH CENTER BY JULY 2 nd Failure to submit a completed Health Record will result in the inability to register for 2 nd semester classes. Once your physician has completed and signed pages 4, 5, and 6 the form may be delivered, mailed, or faxed. CONTACT INFORMATION Name: Student ID: College you are entering: Gender: Home Address: Last First Middle Date of Birth: Class of: Entrance Date: Number Street Home Phone: City State Zip Code Cell Phone: Address: Parent s Address: Please list up to three people whom we can contact in case of emergency: Name Relationship Home phone Work/cell phone ALLERGIES Do you have any allergies to the following? Foods Latex Medications Please specify: Will you be receiving allergy injections at the Student Health Center? Yes No Name: Student ID #: 2
3 MEDICAL HISTORY Indicate below if you have ever experienced any of these problems, please circle Yes. If you are currently experiencing any of these problems, please circle Currently. EYE URINARY Corrective Lenses/Contacts Yes Currently Kidney Stones Yes Currently Problems Yes Currently Urinary Tract Infections Yes Currently ENT MUSCULOSKELETAL Ear Problems Yes Currently Back Problems Yes Currently Disease or Injury of Joints Yes Currently HEART DISEASE High Blood Pressure Yes Currently HEMATOLOGICAL/ ONCOLOGICAL Palpitations Yes Currently Anemia Yes Currently Heart Murmur Yes Currently Cancer Yes Currently RESPIRATORY NEUROLOGICAL/PSYCHOLOGICAL Shortness of Breath Yes Currently Seizures Yes Currently Asthma Yes Currently Headaches Yes Currently Bronchitis Yes Currently Depression Yes Currently Anxiety Yes Currently Eating Disorder Yes Currently ABDOMINAL Irritable Bowel Syndrome Yes Currently Inflammatory Bowel Disease Yes Currently GYNECOLOGICAL Irregular Periods Yes Currently Severe Cramps Yes Currently Ovarian Cyst Yes Currently ENDOCRINE Diabetes Yes Currently Thyroid Yes Currently FAMILY HISTORY Circle all that apply Mother Living Deceased High Blood Pressure Heart Disease Diabetes Thyroid Disease Cancer (specify): Father Living Deceased High Blood Pressure Heart Disease Diabetes Thyroid Disease Cancer (specify): Occupation: Occupation: 3
4 Name: Student ID #: REQUIRED IMMUNIZATIONS NO ATTACHMENTS PLEASE VACCINE DATE LAST BOOSTER DATE DPT (Last date of completed primary series) *TD (Required within last 10 years) or *TDAP (Required within last 10 years) HEP B #1 HEP B #2 HEP B #3 MMR #1 MMR #2 or MEASLES #1 MEASLES #2 MUMPS #1 MUMPS #2 RUBELLA #1 RUBELLA #2 POLIO VACCINE (Last date of completed primary series) MUST HAVE TWO VACCINES VARICELLA #1 VARICELLA #2 OR *TD or TDAP booster is required CHICKEN POX DISEASE TUBERCULOSIS SCREENING - MANTOUX /PPD (within past 365 days) *QUANTIFERON GOLD MUST HAVE TWO VACCINES CIRCLE MENOMUNE/MENACTRA/MENVEO #1 REACTIVE YES NO (please circle) mm *If result is positive, a Quantiferon Gold TB blood test is required. RESULTS: If you received a meningitis shot before age 16, a second shot is required. MENOMUNE/MENACTRA/MENVEO #2 4
5 NON-REQUIRED IMMUNIZATION RECORD Name: Student ID: VACCINE DATE BCG HEP A #1 HEP A #2 HPV #1 (GARDASIL) HPV #2 (GARDASIL) HPV #3 (GARDASIL) TYPHOID YELLOW FEVER OTHER: 5
6 CLINICIAN S FORM CONFIDENTIAL 800 Lancaster Avenue Villanova, PA Phone: (610) Fax: (610) Patient s Name: Student ID. #: TO THE EXAMINING CLINICIAN Please review the patient s history, complete the clinician s form and comment on all positive answers. BP / Height Weight Physical Exam: Eyes WNL : Ears WNL : Nose WNL : Throat WNL : Neck WNL : Lungs WNL : Heart WNL : Abdomen WNL : Lymph glands WNL : G.U. WNL : Skin WNL : Neuro WNL : Musculoskeletal WNL : CURRENT MEDICATIONS: (REQUIRED) Is this patient medically qualified to participate in intracollegiate, intramural or club sport activities? Yes No Clinician s Signature Date exam was completed Clinician s Printed Name Clinician s Address Clinician s Phone # Fax # 6
7 Villanova University Health Center AUTHORIZATION FOR THE RELEASE OF MEDICAL INFORMATION Pennsylvania state law (specifically 35 p.s. Section 10101) requires any minor who is eighteen (18) years of age or older, or has graduated from high school, or has married, or has been pregnant, may give effective consent to medical, dental and health services for himself or herself, and the consent of no other person shall be necessary. I hereby consent to and authorize the health center to release information about my medical condition to my parents/legal guardian. Purpose of the Disclosure: The information may be released in order to keep my parents/legal guardians informed about my general health and medical condition. I authorize disclosure to my parents/legal guardians of all information contained in my medical records. My authorization may be revoked at any time. Signature Printed Name Student ID # Date The Student Health Center does not bill insurance companies. We do request that you send front and back copies of insurance and prescription cards with the health record. This information will be kept on file for emergency use only (i.e. emergency room visit or hospitalization). Form revised: 3/10/14 7
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