The Health and Counseling Center 141 Central Avenue Keuka Park, NY14478 Phone: (315) 279-5368 Fax: (315) 279-5359
OFFICE USE ONLY Rec'd NP Cleared by: Date:
Student Demographic Information Name______________________________________________________________________ Date of Birth_______/_______/_______ Last Name First Name Middle Address_____________________________________________________________________________________________________ Street City State Zip Home Phone: (______) _______________ Cell Phone: (______) __________________
Health Insurance Information Name of Company _______________________________________________ Policy # ____________________________________ Subscriber Name _________________________________________________ Subscriber Date of Birth ________________________ Check All That Apply:
_____Male _____Female _____Freshman _____Residential Student ______Commuter _____Athlete Have you previously attended Keuka College? _____Y _____ N If so, what year did you graduate or stop attending? __________ Has your name changed? If so, what name were you enrolled under? ___________________________________________________
Emergency Contact Information Name ___________________________________________________________________ Relationship: ________________________ Last Name
First Name
Middle
Address ____________________________________________________________________________________________________ Street
City
State
Zip
Home Phone: (______) _______________Work Phone: (______) ______________ Cell Phone: (______) ______________________
Policy Statement and Consent to Treat I hereby authorize the Keuka College Health services to provide medical care upon my request. I also acknowledge that the information provided on this form is accurate to the best of my knowledge. I understand that this form is CONFIDENTIAL and for the Health and Counseling Center use only; it will not be released without the student’s consent, and it will not affect admission status. Note to Athletes: Your signature below authorizes the release of this information between the Health and Counseling Center and the athletic training staff at Keuka College. All information must be in English. To be sure that your health form is considered complete, please do not leave ANY answers blank. Students who are not compliant will be suspended from Keuka College 30 days after classes start and will be reinstated only when proper documentation has been received at the Health and Counseling Center. If the State reviews our files and finds that a student is not compliant, the College is fined. This fine of approximately $2,000.00 is added to the student’s bill. Signature of student ___________________________________________________________ Date __________________________ Signature of parent/guardian ____________________________________________________ Date __________________________ (Needed if student is under age 18.)
Medical History Name all current medications including prescription, birth control, over-the-counter, herbs, homeopathic medications and food supplements, and vitamins, if none please write the word “none”: ______________________________________________________ ___________________________________________________________________________________________________________ Name all medications, foods, insects or other things that cause difficulty breathing, hives or a life threatening reaction, if none please write the word “none”: ________________________________________________________________________________________ ___________________________________________________________________________________________________________ Exercise: Type and frequency___________________________________________________________________________________ Cigarette/tobacco use: Yes___ No___ Age started_____ Average #/day______ Age stopped______ Alcohol use: Yes___ No___ Average number drinks/week______ Other Significant Medical Problems or birth defects:_____________________________________________________ Hospitalization/Reason/Dates:____________________________________________________________________ Surgeries/Reason/Dates:________________________________________________________________________ 1
Name _____________________________________________________________________ Date of Birth_______/_______/_______
Family Medical History If any of your blood relatives have had the diseases listed below please check in the space provided. ______Arthritis _______Heart disease/Stroke ______Asthma _______Kidney disease ______Cancer _______Mental Illness ______Diabetes _______ Premature death from cardio vascular disease ______Digestive Problems at age younger than 50 ______Drug/Alcohol problems _______ Obesity ______Epilepsy/seizures _______ Hereditary Disorder: _______________ ______High blood Pressure
Personal History Please check and comment on all that apply for you. Please explain further if needed by attaching a page.
1. Infectious Diseases Chicken Pox: If yes what date: _____/_____/______ Mononucleosis Rheumatic fever Scarlet fever 2. Eyes, Ears, Nose and Throat Blindness Deafness Hearing Loss Seasonal allergies Sinus disease Wear glasses or contacts 3. Cardiopulmonary Asthma Bronchitis/pneumonia Fainting/dizziness Heart disease/murmur High cholesterol High blood pressure Mitral valve prolapse 4. Gastroenteric Crohn’s disease Ulcerative colitis Reflux/GERD/ulcer Gall bladder disease Hepatitis –Type:________ Hernia Irritable/spastic bowel Regular laxative use Pancreatitis/pancreatic disease 5. Urinary Cystitis/bladder infection Kidney disease Kidney infection/pyelonephritis Kidney stone(s) 6. Musculoskeletal Arthritis Bone or joint deformity Broken bone(s) Rheumatoid disorder
Past
Current Never
Past Current Never 7. Hematologic or Oncologic Anemia Hemophilia Leukemia or lymphoma Sickle cell disease Other blood disorder Cancer:_______________ 8. Neuropsychiatric ADD/ADHD Cerebral palsy Drug/alcohol addiction/abuse Eating disorder Epilepsy (seizures) Learning disability Migraines Recurrent/severe headaches Serious head injury Have you ever been in counseling or had a mental health diagnosis? ____ Yes _____ No If so, please explain __________________________________________________ ________________________________________ Would you like a Keuka College Mental Health Counselor to contact you? ______ Yes _____ No 9. Metabolic Diabetes Thyroid disease 10. Sexual Health Positive HIV Antibody Abnormal Pap smear Breast Lump DES exposure (maternal) Endometriosis Menstrual Abnormalities Ovarian Cysts Poly cystic ovarian disease Testicular injury Testicular Lump Undescended or absent testicle Hydrocele or varicocele
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Tuberculosis (TB) Screening Questionnaire to be Completed By the Student Name ___________________________________________________________ Date of Birth_______/_______/_______ 1: Have you ever had a positive TB skin test? ___ Yes ___ No 2: Have you ever had close contact with anyone who was sick with TB? ___ Yes ___ No 3: Were you born in one of the countries listed below? * (If yes, please CIRCLE the country) ___ Yes ___ No 4: Have you ever traveled** to/in one or more of the countries listed below? (If yes, please CHECK the country/ies) ___ Yes ___ No 5: Have you ever been vaccinated with BCG? ___ Yes ___ No If answer is yes, when did you have it? ___/____/______ ** The significance of the travel exposure should be discussed with a health care provider and evaluated. Angola Azerbaijan Bangladesh Belarus Botswana Brazil Cambodia Cameroon Central African Rep. Chad China Congo Congo DR Ethiopia Ghana Guatemala Guinea-Bissau
Haiti India Indonesia Kazakhstan Kenya Korea-DPR Kyrgyzstan Lesotho Liberia Mexico Moldova-Republic Mozambique Myanmar Namibia Nigeria Pakistan Papua New Guinea
Peru Philippines Russian Federation Somalia South Africa Swaziland Tajikistan Tanzania-UR Thailand Uganda Ukraine Uzbekistan Viet Nam Zambia Zimbabwe
Source: World Health Organization 2015 TB High Burden Country Stop TB Partnership website @http://www.stoptb.org.countries/tbdata.asp
If you answer YES to any of the above questions: Keuka College requires that a health care provider complete a tuberculosis risk assessment (to be completed within 6 months prior to the start of classes). If the answer NO to all of the above questions: No further testing or further action is required.
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Tuberculosis (TB) Risk Assessment to be Completed By the Health Care Provider Name ________________________________________________________________ Date of Birth_______/_______/_______ Persons with any of the following are candidates for either Mantoux tuberculin skin test (TST) or Interferon Gamma Release Assay (IGRA), unless a previous positive test has been documented. Risk Factors to be assessed by health care provider: 1: Recent close contact with someone with infectious TB disease ___ Yes ___ No 2: Foreign-born from (or travel* to/in) a high-prevalence area (e.g., Africa, Asia, Eastern Europe, or Central or South America) ___ Yes ___ No 3: Fibrotic changes on a prior chest x-ray suggesting inactive or past TB disease ___ Yes ___ No 4: HIV/AIDS ___ Yes ___ No 5: Organ transplant recipient ___ Yes ___ No Immunosuppressed (equivalent of > 15 mg/day of prednisone for >1 month or TNF-αantagonist) ___ Yes ___ No 6: History of illicit drug use ___ Yes ___ No 7: Resident, employee, or volunteer in a high-risk congregate setting (e.g., correctional facilities, nursing homes, homeless shelters, hospitals, and other health care facilities) ___ Yes ___ No 8: Medical condition associated with increased risk of progressing to TB disease if infected [e.g., diabetes mellitus, silicosis, head, neck, or lung cancer, hematologic or reticuloendothelial disease such as Hodgkin’s disease or leukemia, end stage renal disease, intestinal bypass or gastrectomy, chronic malabsorption syndrome, low body weight (i.e., 10% or more below ideal for the given population)] ___ Yes ___ No * The significance of the travel exposure should be discussed with a health care provider and evaluated. 1. Does the student have signs or symptoms of active tuberculosis disease? Yes _____ No _____ If No, proceed to 2 or 3. If Yes, proceed with additional evaluation to exclude active tuberculosis disease including tuberculin skin testing, chest x-ray, and sputum evaluation as indicated. 2. Tuberculin Skin Test (TST) (TST result should be recorded as actual millimeters (mm) of induration, transverse diameter; if no induration, write “0”. The TST interpretation should be based on mm of induration as well as risk factors.)** Date Given: _____/_____/_____ Date Read: _____/_____/_____ (must be read within 48 to 72 hours) Result: __________ mm of induration **Interpretation: positive______ negative______ Date Given: _____/_____/_____ Date Read: _____/_____/_____ Result: __________ mm of induration **Interpretation: positive______ negative______ 3. Interferon Gamma Release Assay (IGRA) Date Obtained: _____/_____/_____ (specify method) QFT-G QFT-GIT other_______ Result: Negative_____ Positive_____ Intermediate____ Date Obtained: _____/_____/_____ (specify method) QFT-G QFT-GIT other_______ Result: Negative_____ Positive_____ Intermediate____ 4. Chest X-Ray: (Required if TST or IGRA is positive) – MUST ATTACH COPY OF X-RAY REPORT Date of Chest X-Ray: _____/_____/_____ Result: normal_____ abnormal_____ **Interpretation guidelines >5 mm is positive: • Recent close contacts of an individual with infectious TB • Persons with fibrotic changes on a prior chest x-ray consistent with past TB disease • Organ transplant recipients • Immunosuppressed persons: taking > 15 mg/d of prednisone for > 1 month; taking a TNF-α antagonist • Persons with HIV/AIDS
>10 mm is positive (continued): • History of resident, worker or volunteer in high-risk congregate settings • Persons with the following clinical conditions: silicosis, diabetes mellitus, chronic renal failure, leukemias and lymphomas, head, neck or lung cancer, low body weight (>10% below ideal), gastrectomy or intestinal bypass, chronic malabsorption syndromes >15 mm is positive: • Persons with no known risk factors for TB disease
>10 mm is positive: • Persons born in a high prevalence country or who resided in one for a significant* amount of time • History of illicit drug use • Mycobacteriology laboratory personnel
*The significance of the exposure should be discussed with a health care provider and evaluated.
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To Be Completed By the Health Care Provider PHYSICAL EXAMINATION (required): A physical is valid if completed within the year prior to the first scheduled class date. Student Name: _________________________________________________ DOB: ____/____/____Date of Physical: ____/____/____ Exam: Height: _________ Weight: _______ BP: __________ P: _________ T: _________ BMI: _______ Vision: L ______R______ √ Check = Normal Circle = N/A Blank = Not Examined ____General: healthy appearing, in no acute distress
Note Variances, Abnormal or Significant Findings
____ Skin: Warm, pink, dry with no rash or lesions ____Head/Face: Normcephalic. Normal Hair Growth ____Eye: Sclera white. PERRLA. ____Nose/Sinuses: Sinuses nontender to palpation, nares ____Ears: No pain when helix pulled. External canal normal. TM with light reflex and landmarks present without erythema, injection, bulging, fluid, retraction, perforation or drainage. No hearing loss. ____Oral/Pharynx: Good dental hygiene. No tonsilar hypertrophy. No erythema, swelling, injection, exudate or lesions of palate/pharynx. Uvula midline. ____Neck: Supple with full ROM. No cervical adenopathy. No thyromegaly. ____Respiratory: Respirations easy and nonlabored. Aerates all lobes well. Lungs clear to auscultation and percussion. No pleural rub heard. ____Cardiovascular: Regular S1, S2 without murmur, gallop or rub. No peripheral edema. ____Abdomen: Soft, nondistended with active bowel sounds x 4. No hepatosplenomegaly. No abdominal guarding, rigidity, tenderness or masses on palpation. No CVA tenderness. ____Muscloskeletal: Extremities with full ROM, no varicosities. ____Neurologic: Oriented x 3. Cranial nerves II-XII intact. ____Breast: Symmetrical, no masses/lumps, no dimpling, no palpable nodes, no nipple discharge, no retraction, no tenderness, BSE discussed. ____Genitourinary: External genitalia and hair distribution WNL, inguinal nodes WNL, no urethral lesions or tenderness. Other tests/labs done: _____________________________________________________________________________________________________
Statement as to student’s physical and mental status, and any restrictions: Yes No Any pertinent physical findings (e.g. heart murmur, etc.) Specify:__________________________________________________ Yes No Any recommendations for limitation of physical activity? Specify:__________________________________________________ Yes No Is this individual under care for a chronic condition or serious illness? If yes, attach letter of recommendations. Yes No Any recommendations for special dietary requirements? Specify:__________________________________________________ YesNo Any recommendations for special housing considerations? Specify:___________________________________________ YesNo Any allergies to medications or foods? Specify:__________________________________________________________ Required for all students: ________Unrestricted athletic participation ________Conditional athletic participation
________ No participation ________ List further medical evaluation needed before participation allowed.
If NO, what restrictions apply? ________________________________________________________________________________ Health Provider Signature____________________________________________________________________________ Date_____/_____/_____ Printed Name _____________________________________________ Phone: (______) __________________ Fax: (______) _________________ Address_____________________________________________City__________________________State___________Zip____________________
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Student Name: ______________________________________________________________Date of Birth_______/_______/_______ IMMUNIZATION RECORD: Immunization record to be filled out and signed by a health care provider not a parent. All students born on or after January 1, 1957 must include documented proof of immunity to measles, mumps, and rubella as required by New York State Public Health Law 2165. Immunization records may also be accepted from previous high schools, colleges, the military or other official sources. Students who are not compliant will be suspended from Keuka College 30 days after classes start and will be reinstated only when proper documentation has been received at the Health and Counseling Center. If the State reviews our files and finds that a student is not compliant, the College is fined. This fine of approximately $2,000.00 is added to the student’s bill. Disease
Vaccination Type #1
Vaccination Type #2
OR Serology N/A
MMR Dates OR: Measles (Rubeola) 2 doses required Mumps- one dose German Measles (Rubella)
N/A
OR MD Diagnosis Of disease N/A
N/A
TETANUS-DIPHTHERIA (required): Tetanus-Diphtheria (Td) booster within the last ten years: Td ___/___/___ OR Tdap ___/___/___
MENINGOCOCCAL (required for residential students): A meningococcal meningitis vaccine after age 16. Date ___/___/___ ______ Menactra or _____ Menveo (Please indicate which vaccine given) HEPATITIS B Series: (required for Nursing and OT students, recommended for all others): Three doses of vaccine or a positive Hepatitis B surface antibody. Dose 1 ___/___/___ Dose 2 ___/___/___ Dose 3 ___/___/___ Recommended: Hepatitis B surface antibody Date ___/___/___ Result: Reactive______ Non-reactive______ INFLUENZA (recommended): Annual immunization recommended to prevent disruption of academic activities. Dates: ___/___/___ ___/___/___ ___/___/___ ___/___/___ ___/___/___ CHICKEN POX (required for residential students): Vaccination or serology Dose 1 ___/___/___ Dose 2 ___/___/___ Serology ___/___/___ Result ___________ LIST OF CURRENTLY PRESCRIBED MEDICATIONS: 1.
___________________
3. _____________________ 5. ____________________ 7. ____________________
2.
___________________
4. _____________________ 6. ____________________ 8. _____________________
Please indicate if these prescriptions can be filled by our Nurse Practitioner in the Keuka College Health and Counseling Center, or if they will need to contact their primary physician for refills. ____________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Health Care Provider Signature______________________________________________________________ Date_____/_____/_____ Printed Name _________________________________________ Phone: (______) __________________ Fax: (______) __________ Address_______________________________________City__________________________State___________Zip_______________
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