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Student Name:______Student ID:______
STUDENT HEALTH REPORTING FORM
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Student Name:______Student ID:______
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Student Name:______Student ID:______
Health Center
620 University Avenue, Selinsgrove, PA 17870-1001
Phone (570) 374-9164/ Fax (570) 372-2729
Health Center Webpage –
Counseling Center - Phone (570) 372-4751/ Fax (570) 372-2776
Athletic Department - Phone (570) 372-4270/ Fax (570) 372-2758
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Student Name:______Student ID:______
Information you provide will not be used to influence your situation at the university; it will be used solely as an aid to provide health care while you are a student. In the future, medical information shared with the Health Center would be strictly for the use of the Health Center; sharing of medical information will be governed by the enclosed HIPAA regulations. The above-named offices would not share future information without the consent of the student.
Must be returned to the Health Center before July 15
or a hold will be placed on your registration, athletic participation,and/or your room key will be held.
SECTIONS I, II, and III TO BE COMPLETED BY STUDENT (PLEASE PRINT NEATLY INBLACK INK)
Part I – PERSONAL DATA
Name:
Last First Middle
Date of Birth:// Social Security No.: - -
Month Day Year
Semester you are entering (circle): Fall SpringClass you are entering (circle): FR SO JR SR
Previously enrolled at Susquehanna University (circle): No Yes If Yes, year(s) enrolled:
Sport(s) you plan on participating in at Susquehanna University:
Female Male Transgender Marital Status: Citizenship: Religion:
Home Address:
No. & Street City/Town State Zip
Birth State: Country of Origin if other than United States:
Home Phone: Student’s Cellular Phone:
In case of an emergency notify:
Name Relationship Home Phone
Home Address Cellular Phone Business Phone
Family Physician: Phone:
Address:
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Student Name:______Student ID:______
Part II – FAMILY AND PERSONAL HISTORY
Do you have any known allergies? If so, please list:
Yes / No / Specify Allergy: Epi Pen: / Yes / NoDrug
Food
Insect Sting/Bite
Other
Has any person, related by blood, had any of the following:
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Student Name:______Student ID:______
Yes / No / RelationshipAlcohol/Drug Problems
Blood or Clotting Disorder
Cholesterol or Blood Fat Disorder
Diabetes
Glaucoma
Heart Attack Before Age 55
High Blood Pressure
Psychiatric Illness
Stroke
Yes / No / Relationship
Cancer – SpecifyType:
Has any member of your family died suddenly under the age of 50? If yes, cause of death:____
______
Suicide
Other – Specify:
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Student Name:______Student ID:______
Have you ever had or do you now have: (please check at right of each item and if “yes”, indicate year of first occurrence)
Yes / No / YearAbdominal – Specify:
Appendicitis
Bleeding from Rectum
Hernia
Injury to Kidney
Injury to Spleen
Stomach Trouble – Specify:
Allergy Injection Therapy
Asthma
Blood Pressure Issues – Specify High / Low:
Blood Problems – Specify:
Anemia
Sickle Cell Anemia
Sickle Cell Trait
Transfusion
Cancer – Specify:
Chicken Pox
Cysts or Lumps – Specify:
Dermatology (Skin Disorder) – Specify:
Diabetes
Ear, Nose, Throat Problems – Specify:
Epilepsy / Seizures
Eye Problems – Specify:
Frequent Headaches
Gall Bladder Trouble or Gallstones
Head Problems – Specify:
Heart Problems – Specify:
Syncopal Episode
Chest Pain
Dizziness
Extra Heart Beat
Heart Murmur
Rheumatic Fever
Other – Specify:
Yes / No / Year
Hearing Loss
Hypoglycemia
Infectious Mononucleosis
Jaundice or Hepatitis
Malaria
Neurological Issues– Specify:
Head Injury – Specify:
Concussion – Specify:
Fracture – Specify:
Unconsciousness – Specify
Other – Specify:
Neck Injury – Specify:
Fracture – Specify:
Pinched Nerve – Specify:
Other – Specify:
Orthopedic Problems – Specify:
Ankle – Specify:
Arm/Elbow/Wrist/Hand/Fingers – Specify:
Back/Ribs – Specify:
Foot – Specify:
Hip/Groin – Specify:
Knee – Specify:
Lower Leg – Specify:
Shoulder – Specify:
Thigh – Specify:
Other (Stress Fracture, Etc.) – Specify:
Paralysis
Personal Trauma
Pilonidal Cyst
Sexually Transmitted Disease – Specify:
Smoke - Number of Cigarettes a Day:______
Thyroid Problems – Specify:
Tuberculosis
Urinary / Kidney Problems – Specify:
Other health problems including hospitalizations or surgical operations – Specify:
Have you ever had episodes of unexplained shortness of breath, wheezing or chest pain? – Specify:
Are you taking any medications routinely? – Specify:
Please mark “YES” if any organs are NOT intact – Specify:
Eyes
Kidneys
Lungs
Testes (Ovaries/Testicles)
Other – Specify:
If there is other medical history important to your safety or to the safety of others, please report it below:
THIS SECTION TO BE COMPLETED BY FEMALES ONLY:
Have you ever had any gynecological / obstetrics issues? – Specify:
Are you pregnant?
Menstrual Disorder – Specify:
Part III – MENTAL HEALTH/SOCIAL HISTORY
Please note that mental health, like all of your health information, is confidential. The Health Center and the Counseling Center are separate departments. In the future, a consent signed by the student will be obtained before sharing any additional health information. If you wish to discuss mental health issues with a counselor or coordinate an appointment, please call the Counseling Center at 570-372-4751.
Have you ever had or do you now have:
(Please check at right of each item and if “Yes”, indicate year of first occurrence.”)
Yes / No / YearDepression
Anxiety
Bipolar disorder
Eating disorder
Alcohol/drug abuse or dependence
Other mental health concerns – Specify:
Please indicate if you have had the following experiences:
Yes / No / YearAttended counseling for mental health concerns
Taken a prescribed medication for mental health concerns
Been hospitalized for eating disorder / mental health concerns
Received treatment for alcohol or drug abuse
Part IV and V - To be completed by a health care provider
Must be returned to the Health Center before July 15
or a hold will be placed on your registration, athletic participation and/or your room key will be held.
Part IV – REPORT OF PHYSICAL EXAMINATION
Physical MUST be completed within six months prior to the first day of classes, which begin August 31, 2015.
Name:
Last First Middle
Date of Entry to SU: Date of Birth: Social Security No.: - -
Date of Physical: (Must be completed within six months prior to the first day of classes on August 31, 2015.)
Temperature: Pulse: Respiration:
Height: Weight: BP:
Are there abnormalities of the following systems? Please describe fully.
System / Yes / No / Comments1. Head, Ears, Nose or Throat
2. Respiratory
3. Cardiovascular
4. Gastrointestinal
5. Hernia
6. Eyes
7. Genitourinary
8. Musculoskeletal
9. Metabolic/Endocrine
10. Neuropsychiatric
11. Skin
Is there loss or seriously impaired function of any organ? No Yes Explain:
Recommendations for physical activity: Unlimited Limited Explain:
Athlete’s clearance for full physical activity (please check one):
Granted
Granted with restrictions Specify:
Postponed until
RejectedReason:
Other Recommendations:
Orthopedic screening findings or comments:
Has the patient ever been treated for an eating disorder? No Yes Explain:
Has the student ever been treated for any other mental health condition? No Yes Explain:
Is the student currently under treatment or had treatment within the past year for any medical or mental health condition? No Yes Explain:
Continue to next page…….
Do you have documentation of a sickle cell trait test? No ______Yes ______Results: Positive______Negative______Unknown______
Do you have any recommendations regarding the care of this student? No Yes Explain:
How long have you known this student? Do you have any general comments?
If you have any additional recommendations, please feel free to include a note or letter with this health record.
*************************************************************************************************************************************************************************************************************************************************
MUST BE SIGNED BY HEALTH CARE PROVIDER:
Health Care Provider’s Name Printed:
Health Care Provider’s Signature: Date:
Address:
Phone: ( ) Fax: ( )
Part V – IMMUNIZATION RECORD
To be completed and signed by a health care provider - Dates must include month(M), day(D) (if available)and year(Y).
All information, including dates, must be placed on the SU form and must be in English.
The following immunizations are for your protection as well as that of the University community.
Must be returned to the Health Center before July 15 or a hold will be placed on your registration, athletic participation and/or your room key will be held.
If you have problems obtaining your immunizations, contact your local Department of Health or high school for possible assistance.
Section I
The following immunizations are recommended but not required
A. Human Papillomavirus Vaccine (HPV2 or HPV4)
(Three doses of vaccine for female and male college students 11-26 years of age at 0, 2 and 6 month intervals.)
Immunization (indicate which preparation) Quadrivalent (HPV4) or Bivalent (HPV2)
a. Dose #1 / / b. Dose #2 / / c. Dose #3 / /
M D Y M D Y M D Y
B. Hepatitis A
1. Immunization (hepatitis A)
a. Dose #1 / / b. Dose #2 / /
M D Y M D Y
2. Immunization (combined hepatitis A and B vaccine)
a. Dose #1 / / b. Dose #2 / / c. Dose #3 / /
M D Y M D Y M D Y
C. Serogroup B Meningococcal Vaccines (MenB)
1. MenB (Bexsero®, Novartis)
a. Dose #1 / / b. Dose #2 / /
M D Y M D Y
OR (either 1 or 2)
2. MenB (Trumenba®, Pfizer)
a. Dose #1 / / b. Dose #2 / /
M D Y M D Y
Note: Use of brand names is not meant to preclude the use of other meningococcal vaccines where appropriate.
Continue to next page…….
Section II
The following are REQUIRED immunizations.
A. MMR (Measles, Mumps, Rubella) – Two doses required at least 28 days apart for students born after 1956 and all
health sciences students.
1. Dose 1 given at age 12-15 months or later……………………………………………………….…………….#1 / /
M D Y
2. Dose 2 given at age 4-6 years or later, and at least 28 days after first dose…………...…..……………....#2 / /
M D Y
B. Tetanus, Diphtheria, Pertussis– Primary series with DtaP or DTP and booster with Tdap in the past 10 years meets
requirements.
1. Primary series completed? Yes No
Date of last dose in series: / /
M D Y
2. Date of most recent booster dose: / /
M D Y
Type of booster: Td Tdap
Tdap booster recommended for ages 11-64 unless contraindicated.
C. Hepatitis B- Three doses of vaccine or two doses of adult vaccine or a positive hepatitis B surface antibody meets the
requirement.
1. Immunization (hepatitis B)
a. Dose #1 / / b. Dose #2 / / c. Dose #3 / /
M D Y M D Y M D Y
2. Hepatitis B surface antibody: Date / / Result: Reactive Non-reactive
M D Y
D. Meningococcal – (A, C, Y, W-135) One or two doses for all college students. This is required for all students residing in a
residence hall. A second dose is required if primary dose was administered before 16th birthday.
1. Quadrivalent conjugate
a. Dose #1 / / b. Dose #2 / /
M D Y M D Y
2. Quadrivalent polysaccharide (acceptable alternative if conjugate not available) Date / /
M D Y
E. Varicella – History of chicken pox, positive varicella antibody or 2 doses of vaccine meetrequirements.
1. History of Disease: Yes No
2. Varicella antibody: // Result: Reactive Non-reactive
M D Y
3. Immunization:
a. Dose #1……………………..………………..…………………………………………….……….#1 / /
M D Y
b. Dose #2 –Given at least 12 weeks after first dose ages 1-12 years and at least 4 weeks after first dose if age 13 years or
older………....…………………………………………………………………...…….…………….#2 / /
M D Y
F. Polio – Primary series, doses at least 28 days apart. Three primary series schedules are acceptable.
1. OPV alone (oral Sabin three doses): #1 / / #2 / / #3 / / .
M D Y M D Y M D Y
2. IPV alone (injected Salk four doses): #1 / / #2 / / #3 / / #4 / /
M D Y M D Y M D Y M D Y
Continue to next page…….
G. PART I: Tuberculosis (TB) Screening Questionnaire (to be completed by incoming students)
Please answer the following questions:
Have you ever had close contact with persons known or suspected to have active TB disease? □ Yes □ No
Were you born in one of the countries listed below that have a high incidence of active TB disease? □ Yes □ No
(If yes, please CIRCLE the country, below)
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Student Name:______Student ID:______
Afghanistan
Algeria
Angola
Argentina
Armenia
Azerbaijan
Bahrain
Bangladesh
Belarus
Belize
Benin
Bhutan
Bolivia (Plurinational
State of)
Bosnia and
Herzegovina
Botswana
Brazil
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde Cambodia
Cambodia
Cameroon
Central African
Republic
Chad
China
Colombia
Comoros
Congo
Côte d'Ivoire
Democratic People's
Republic of
Korea
Democratic Republic
of the Congo
Djibouti
Dominican Republic
Ecuador
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Gabon
Gambia
Georgia
Ghana
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
India
Indonesia
Iran (Islamic
Republic of)
Iraq
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's
Democratic
Republic
Latvia
Lesotho
Liberia
Libya
Lithuania
Madagascar
Malawi
Malaysia
Maldives
Mali
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
(Federated
States of)
Mongolia
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Nicaragua
Niger
Nigeria
Niue
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Republic of Korea
Republic of Moldova
Romania
Russian Federation
Rwanda
Saint Vincent and
the Grenadines
Sao Tome and
Principe
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Solomon Islands
Somalia
South Africa
South Sudan
Sri Lanka
Sudan
Suriname
Swaziland
Tajikistan
Thailand
Timor-Leste
Togo
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Republic of
Tanzania
Uruguay
Uzbekistan
Vanuatu
Venezuela
(Bolivarian
Republic of)
Viet Nam
Yemen
Zambia
Zimbabwe
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Student Name:______Student ID:______
Source: Supplement – 2012 TB Incidence Rate Updated
Have you had frequent or prolonged visits* to one or more of the countries listed above with a high □ Yes □ No
prevalence of TB disease? (If yes, CHECK the countries)
Have you been a resident and/or employee of high-risk congregate settings (e.g., correctional facilities, □ Yes □ No
long-term care facilities and homeless shelters)?
Have you been a volunteer or health-care worker who served clients who are at increased risk for active □ Yes □ No
TB disease?
Have you ever been a member of any of the following groups that may have an increased incidence of □ Yes □ No
latent M. tuberculosis infection or active TB disease – medically underserved, low-income or abusing
drugs or alcohol?
If the answer is YES to any of the above questions, Susquehanna University requires that you receive
TB testing as soon as possible but at least prior to the start of the subsequent semester.
IMPORTANT NOTE: If the answer to all of the above questions is NO (PLEASE STOP HERE – SKIP PART II AND PART III), no further testing or further action is required.
* The significance of the travel exposure should be discussed with a health care provider and evaluated.
PART II: Clinical Assessment by Health Care Provider(only complete this section if answered YES to any PART I question)
Clinicians should review and verify the information in Part I. Persons answering YES to any of the questions in
Part I are candidates for either Mantoux tuberculin skin test (TST) or Interferon Gamma Release Assay (IGRA),
unless a previous positive test has been documented.
History of a positive TB skin test or IGRA blood test? (If yes, document below.) □ Yes □ No
History of BCG vaccination? (If yes, consider IGRA if possible.) □ Yes □ No
Continue to next page…….
1. TB Symptom Check- (only complete this section if answered YES to any PART I question)
Does the student have signs or symptoms of active pulmonary tuberculosis disease? □ Yes □ No
If No, proceed to either step 2 or step 3 below.
If yes, check all that apply below:
□ Cough (especially if lasting for 3 weeks or longer) with or without sputum production
□ Coughing up blood (hemoptysis)
□ Chest pain
□ Loss of appetite
□ Unexplained weight loss
□ Night sweats
□ Fever
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) - (only complete this section if answered YES to any PART I question)
(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://
M D Y M D Y
Result:mm of induration **Interpretation: positive negative
Date Given: / / Date Read://
M D Y M D Y
Result: mm of induration **Interpretation: positive negative
**Interpretation guidelines:
**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 and other immunosuppressed persons (including receiving equivalent of >15 mg/d of prednisone for >1 month.)
- HIV-infected persons
>10 mm is positive:
- recent arrivals to the U.S. (<5 years) from high prevalence areas or who resided in one for a significant* amount of time
- injection drug users
- mycobacteriology laboratory personnel
- residents, employees, or volunteers in high-risk congregate settings
- persons with medical conditions that increase the risk of progression to TB disease including silicosis, diabetes mellitus, chronic renal failure, certain types of
cancer (leukemias and lymphomas, cancers of the head, neck or lung), gastrectomy or jejunoileal bypass and weight loss of at least 10% below ideal body
weight.
>15 mm is positive:
- persons with no known risk factors for TB who, except for certain testing programs required by law or regulation, would otherwise not be tested.
* The significance of the travel exposure should be discussed with a health care provider and evaluated.
3. Interferon Gamma Release Assay (IGRA) - (only complete this section if answered YES to any PART I question)
Date Obtained: / / (specify method) QFT-GIT T-Spot other