Professional Documents
Culture Documents
Healt Form th m
NursingStudentsCheckHe ere
Admission for: Spring In nternationalE ExchangeStudentsCheckHere g Summer Fall Ho omeCountry:___________ _____________ _________ (Circle on ne)20____ _____
_______ __________ __
BU ID Num mber Cell Phone # e
_____ ________
Birthd date
____ __________ _________ _________ _________ ______ ____ __________ _________ _________ _________ ______
The dates of the followi ing immunizations (n numbers 1 t through an including 4) must be listed. nd Wi ithout thes dates, yo health form/statu will be c se our f us considered incomplete which wi prevent e ill you from sch heduling an nd/or regist tering for classes. Y may con c You ntact the following sourc for a ces cop of your im py mmunization records: fa n amily doctor, high schoo PA Dept. of Health, B , ol, Baby book wi ith imm munization records. r
1.
M MMR I: Date __________ MMR II: Date: _______ e: ___ D _______ Two doses, given 4 weeks apa after the f o n art, first birthday, , a required fo students bo after 1956 Positive Rubella, Rub are or orn 6. R beola and Mum titers are acceptable to meet this mps e o r requirement.
R Rubeola Titer: Positive Negative : D Date: _______ ________ Mumps Titer Positive Negative r: Date: _____ __________ Rubella Ti iter: Positiv ve Date: ___ ____________ Negativ ve
2.
V Varicella req quirement th hree differen options: Varicella (Chi nt V ickenpox) 1.) Provide the Y ) Year of Disease __________ or e: __,
2 Immunizat 2.) tion: Two Doses Required at least 4 weeks apart: Da of Dose #1__________ Date of Dose #2__________ or d ate __, 3 Varicella titer: Po 3.) t ositive Negative Date: ______ ______
3. T Tetanus:
A Tetanus Toxoid booster is given routin every 10 years. Tdap booster is giv one time as a s nely ven r replacement to the regular Tetanus boos to protect against Pertu o ster t ussis (whoopi cough). ing
Last Td Boo ster Date: ___ ____________ _________
4. 5.
H Hepatitis: Th here are two options to meet this requ m uirement: Pr roof of receiv ving the vacc cine or by positive titer. H Hepatitis B: 3 Doses of vac ccine required *: Dose #1: ___________ Dose #2: ___ d __ ____________ Dose #3: ____ _________,
Posit tive
Neg gative
MM MR H B Hep
TST:_______ Hx:______
Pag ge1
HealthForm(Continued)
TST by Mantoux Skin Test (Tuberculin Skin Test) All International students and Nursing students (beginning with sophomore year) must have a Tuberculin skin test (TST by Mantoux method only) within the past 6 months. FOR ALL OTHER STUDENTS, TESTING IS OPTIONAL. International Students, if you have received BCG vaccine, please indicate year that you received this vaccine: ____________ Date of Test ___________ Date of Reading ____________ Negative _____ mm If test Positive: Chest X-ray: Date ____________________ Results: (10mm or greater) Positive ______ mm Positive X-ray
Negative X-ray
MeningitisImmunizationInformationandWaiver
Studentslivingincampushousingarerequiredbylaw(Senatebill95506252002)toshowevidenceof meningitisvaccinationorsignawaiverstatingthatthroughinformedconsenttheyrefusethisvaccine.Please readtheinformationregardingMeningitisfoundbelow.Currentlytherearesafeandeffectivevaccinesavailable toprotectagainstthemostcommonsubtypesofmeningitisbacteria.Aswithanyvaccine,protectionmaynotbe 100%.Thisvaccinedoesnotprotectagainstviralmeningitis. IfyouhavereceivedMenactra*,Menomune**,orMenveo(anyofwhichisacceptable),pleaseindicatethedate ofvaccinationatthebottomofthispage.*TheMenactravaccineshouldberepeatedifitwasgivenmorethan5 yearsago.**TheMenomunevaccinationshouldberepeatedifitwasgivenmorethan3yearsago.Ifyoudonot wishtoreceivethemeningitisvaccine,pleaseindicatethisdecisionbysigningthewaiveralsoatthebottomofthis page.Pleaseprintyournameclearlyfollowingyoursignature.
GeneralInformation Collegestudentsareatincreasedriskformeningitis,apotentiallyfatalbacterialinfection.Freshmenlivingincollege residencehallshaveasixfoldincreasedriskforthedisease.Statisticsshowthat6570%ofcasesofmeningococcaldisease incollegestudentsarevaccinepreventable. Whatismeningitis:Meningitisisaninflammationoftheprotectivemembranescoveringthebrainandspinalcord.The inflammationmaybecausedbyinfectionfromviruses,bacteriaorothermicroorganisms.Bacterialmeningitiscanbereadily spreadfrompersontopersonand,ifnotdetectedearly,permanentbraindamage,organfailureand/ordeathmayoccur. Howisitspread?BacterialMeningitisisspreadbyclosecontactwithaninfectedperson.Modesoftransmissioninclude(but notlimitedto)coughing,sneezing,kissing,and/orsharingitemslikeutensils,cigarettes,anddrinkingglasses. Whatarethesymptoms?Initially,flulikesymptomscanbefollowedbyhighfever,severeheadache,stiffneck,rash,nausea, vomiting,confusion,andeventuallycoma. Whoisatrisk?StudentsinResidenceHallsorgroupslivingtogetherinapartments,etc.,arethestudentsmostat [increased]risk,probablybecausethebacteriaisspreadquicklywherevergroupsofsusceptibleyoungadultscongregate. Otherstudentsshouldalsoconsidervaccinationtoreducetheirriskforthisdisease.
ThisSectionMUSTBECOMPLETEDBYALLSTUDENTSLIVINGINCAMPUSHOUSING:
Dateofmostrecentmeningococcalimmunization:___________________
PleaseCirclevaccineyoureceived,ifknown:
MenactraMenomuneMenveo
SignatureofStudent
PrintNameDate
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SelfReportedHealthHistory
______________________________________________________ Last Name First Name M.I. _____________________ BU ID Number _________________ Birth Date
Personal History
Allergies to Medication(s): Specify Type of Reaction: Have you been treated or hospitalized for: (Check All that Apply)
Anxiety Depression
() Yes No
Allergies to Food and Additives: Specify type of Reaction: Are you allergic to Latex? Yes No Check All that Apply Have you had or currently have: Yes Heart Disease or Rhythm Abnormalities (Specify): Reactive Airway Disease (Asthma) Seasonal Allergies Recurrent sinus infections/head colds Recurrent chest colds/bronchitis High or Low Blood Pressure (circle one) Latent Tuberculosis (TB) or Active TB Diabetes Past history of Mononucleosis History of Kidney Disorders Past/Present treatment for Tumor/Cancer Epilepsy/Seizure Disorder Past History Bone/Joint Disease or Injuries (Specify):
() No
Surgical Procedures: (Check All that Apply) Appendectomy (Date) Tonsillectomy (Date) Wisdom Teeth Extraction (Date) Other Surgeries (Specify):
() Yes No
Do you have a history of the following: (Check All that Apply) Tobacco Use Alcohol Use
() Yes No
Problems with Diarrhea or Constipation History of Hepatitis (Specify): History of Rheumatic Fever Recurrent Headaches (Specify):
Recreational Drug Use Performs Regular Self-Breast Exams Performs Regular Testicular Exams Present or past skin conditions (Specify):
Family History
Yes No
Tuberculosis Diabetes Kidney Disease Heart Disease
Yes
No
Relationship
List any medications you take on an ongoing basis with exact dosage. (Please include daily herbal supplements and birth control methods) Medications (List Dosage): 1. 2. 3. Additional Information _________________________________________________________________________________ _____________________________________________________________________________________________ Page3