Winston-salem state University
stUdent HealtH
information reqUirements
A.H. Ray Student Health Center
601 Martin Luther King Jr. Drive, RM 244
Winston-Salem, NC 27110
A. H. RAY STUDENT HEALTH CENTER
601 S. Martin Luther King Jr. Dr., RM 244
Winston-Salem, North Carolina 27110
Guidelines for Completing the Required Report of Medical History Form:
NOTE: Student Health does not share your health history form with other Departments.
Keep a copy of this entire form for your records and mail the original form to the address above.
1. The completion and early submission of this form is required. Please download, complete each area and return
directly to the above address 30 days before your arrival on campus. The information you submit is
important for your care while a student at the University. It will be kept in a secure place in the Student Health
Center. All information is confidential and does not affect your admission status. This information will not be released
without your written permission except in a personal medical emergency or by court order.
2. With the exception of Distance Learners and International students, all students taking 6 or more credit hours are
required to carry health insurance. If you are currently insured, fill in the insurance section entirely and attach a
readable copy of the front and back of your insurance card to this form. Students may waive out of the University’s
mandatory health insurance plan by providing proof of current health coverage by the deadline. For more details, you
may access the health insurance carrier Pearce and Pearce on-line at www.studentinsurance.com.
3. The Family and Personal Health History information you supply is an important tool for you and the Health Service
staff in understanding your health history and needs. The instructions for completion are listed above each section.
4. Student Health Services works with the Registrar’s Office to assure that required immunizations and records have
been received and documented. Please pay special attention to and make sure you have fulfilled all North
Carolina immunization requirements. Prior to coming to campus, see your doctor or contact your
local health department to receive the injections you need. Attach signed copies of any records that verify
your immunizations. Some University Departments require additional immunizations for admittance. Information on
the Meningococcal Vaccine is included with this form for your convenience.
Under North Carolina regulations, a student must be dropped from his or her classes if the
immunization requirements are not met.
5. Your health care provider must sign documentation of a physical exam performed within 6 months of the date prior
to admittance. A dental and eye exam prior to entering the University is highly recommended.
Students With Special Needs
Students with special needs are to visit Student Health upon arrival to campus and supply a copy of medical records
and a current medications list. Special needs conditions include asthma, diabetes, seizure disorders, etc.
Special housing requests must be accompanied by an annually signed doctor’s note stating the medical basis.
The University’s Health Care Provider will review the note and make a recommendation regarding the request.
GUIDELINES FOR COMPLETING IMMUNIZATION RECORD
A certified immunization record* is required by North Carolina State law § 130A-154 in order to meet the NC
Immunization Compliance Law. Non-compliance can result in the University Registrar placing an “Immunization
Hold” on your student account or being “dis-enrolled” from the University.
Note: *Certified immunization records submitted must include:
•
•
•
•
•
Student/patient complete name, address, date of birth and sex
Name and address of the parent, guardian or person responsible for the child obtaining the required immunizations
Name of vaccine administered, number of doses of vaccines given, and complete dates doses were given
Name and address of the physician or local health department administering the required immunization and other relevant
information required by the State of North Carolina
Note: ** An official lab report of a positive antibody Titer by serological testing is acceptable if the report shows the
protective numerical values of antibodies. Values found to be equivocal or below protective values are not acceptable.
Please Keep a Copy for Your Records.
Acceptable Records of your Immunizations may be obtained from any of the following:
•
•
•
•
SECTION A:
•
Personal Shot Records
Local Health Department
Military Records of WHO (World Health Organization Documents)
Previous College or University
COLLEGE/UNIVERSITY VACCINES AND NUMBER OF DOSES REQUIREMENTS
(For further information: http://www.immunize.nc.gov/schools/collegesuniversities.htm)
Diphtheria,
Tetanus
and/or
1
Pertussis
3
Polio
2
3
3
4
Measles
Mumps
2
2
5
Rubella
Hepatitis B
1
6
3
FOOTNOTE 1 – DTP (Diphtheria, Tetanus, Pertussis), DTaP (Diphtheria, Tetanus, acellular Pertussis), Td (Tetanus, Diphtheria), Tdap (Tetanus, Diphtheria, Pertussis): 3 doses of
tetanus/diphtheria toxoid of which one must have been within the past 10 years.
Those individuals enrolling in college or university for the first time on or after July 1, 2008 must have had three doses of tetanus/diphtheria toxoid and a booster dose of
tetanus/diphtheria/pertussis vaccine if a tetanus/diphtheria toxoid and tetanus/diphtheria/pertussis vaccine has not been administered with the past 10 years.
FOOTNOTE 2 – An individual attending school who has attained his or her 18th birthday is not required to receive polio vaccine.
FOOTNOTE 3 – Measles vaccines are not required if any of the following occur: Physician diagnosis of disease prior to January 1, 1994; An individual who has been documented by serological
testing to have a protective antibody titer against measles and submits the lab report; or An individual born prior to 1957. An individual who enrolled in college or university for the first time
before July 1, 1994 is not required to have a second dose of measles vaccine.
FOOTNOTE 4 – Mumps vaccine is not required if any of the following occur: An individual who has been documented by serological testing to have a protective antibody titer against mumps
and submits the lab report; An individual born prior to 1957; or Enrolled in college or university for the first time before July 1, 1994. An individual entering college or university prior to July
1, 2008 is not required to receive a second dose of mumps vaccine.
FOOTNOTE 5 – Rubella vaccine is not required if any of the following occur: 50 years of age or older; Enrolled in college or university before February 1, 1989 and after their 30th birthday; An
individual who has been documented by serological testing to have a protective antibody titer against rubella and submits the lab report.
FOOTNOTE 6 – Hepatitis B vaccine is not required if any of the following occur: Born before July 1, 1994.
INTERNATIONAL STUDENTS and/or non-US Citizens: Vaccines are required as noted above. Additionally, these
students are required to have a Tb skin test (PPD or TST) that has been administered and read at an appropriate medical
facility within the 12 months prior to the first day of class. (Chest x-ray required if test is positive).
SECTION B
These vaccines are RECOMMENDED. Some may be required by certain departments. Consult your college or department
for specific requirements.
North Carolina House Bill 825 requires public and private institutions with on-campus residents to provide information about meningococcal disease. Attached to this
form is information regarding meningococcal disease, including recommendations. from the Centers for Disease Control of the U.S. Public Health Service. Please
record on the front of this form, whether or not you have received the meningococcal vaccine. If, yes, please note the month, day, and year of the vaccination.
SECTION C
These vaccines are optional.
Revised 7/2012
IMMUNIZATION RECORD
LAST NAME
FIRST NAME
MIDDLE NAME
ADDRESS:
Date of Birth
Sex
Banner ID #
NAME, RELATIONSHIP AND ADDRESS OF PARENT OR GUARDIAN:
Please print in black ink. To be completed and signed by physician or clinic. A complete official immunization record from a physician or clinic may be attached to this
form. Student to confirm identifying information above is complete before submission.
SECTION A:
REQUIRED IMMUNIZATIONS
month/day/year
DTP
(#1)
(#2)
Mumps
Rubella
Hepatitis B (required if born 7/1/94 or after)
SECTION B:
RECOMMENDED IMMUNIZATIONS
Meningococcal vaccine:
month/day/year
(#3)
(#4)
**Disease Date
Not Acceptable
***Disease Date
Not Acceptable
***Disease Date
Titer Date & Result
Titer Date & Result
Titer Date & Result
(#1)
(#2)
(#3)
The following immunizations are recommended for all students and may be required by certain colleges or
departments (i.e., health sciences). Please consult with your college or department for specific requirements.
No ( ) Yes ( )
Hepatitis B Series only
month/day/year
Submit
Laboratory
Tdap (if due update after 7/2008)
Tetanus
Polio
MMR (after first birthday)
Measles/Rubella (MR) (after first birthday)
Measles (after first birthday)
month/day/year
Which Vaccine?
month/day/year
Menactra ( ) Menomune ( )
Date Given:
month/day/year
month/day/year
month/day/year
****anti-HBs Date & Result
OR
Hepatitis A/B combination series
Varicella (Chicken Pox) series of two doses or
immunity by positive blood titer
Tuberculin Skin Test (PPD)
Date Read
or TB blood test (within 12 months) Report resulted in
Disease Date
****Titer Date & Result
mm induration
Date
Results
Chest X-Ray, if positive PPD
Treatment, if applicable
SECTION C:
OPTIONAL IMMUNIZATIONS
Date
month/day/year
month/day/year
month/day/year
Haemophilus influenza type b
Pneumococcal
Hepatitis A series only
HPV (Gardasil)
Other
Signature or Clinic Stamp, address, and phone number REQUIRED:
__________________________________________________________
______________________________________
_________________________________________________________________________
Print Name of Physician/Physician Assistant/Nurse Practitioner
_______________________________________________
Phone Number
Signature of Physician/Physician Assistant/Nurse Practitioner
Date
___________________________________________________________________________________________________________________________________
Office Address
City
State
Zip Code
**Must repeat Rubeola (measles) vaccine if received more than 4 days prior to 12 months of age. History of physician-diagnosed measles is acceptable, but must have signed statement from physican.
***Only laboratory proof of immunity to rubella or mumps is acceptable if the vaccine is not taken. History of rubella or mumps disease, even from a physician, is not acceptable.
****Lab report must be submitted.
Revised 7/2012
MENINGOCOCCALVACCINES
WHAT YOU NEED TO
KNOW
Many Vaccine Information Statements are available in Spanish and other languages. See www.immunize.org/vis.
1
What is meningococcal disease?
Meningococcal disease is a serious bacterial illness. It is
a leading cause of bacterial meningitis in children 2
through 18 years old in the United States. Meningitis
is an infection of the fluid surrounding the brain and
spinal cord.
Meningococcal disease also causes blood infections.
Both vaccines work well, and protect about 90% of
people who get them. MCV4 is expected to give better,
longer-lasting protection.
MCV4 should also be better at preventing the disease
from spreading from person to person.
3
Who should get meningococcal
vaccine and when?
About 1,000 - 2,600 people get meningococcal disease
each year in the U.S. Even when they are treated with
antibiotics, 10-15% of these people die. Of those who
survive, another 11-19% lose their arms or legs, become
deaf, have problems with their nervous systems, become
mentally retarded, or suffer seizures or strokes.
A dose of MCV4 is recommended for children and
adolescents 11 through 18 years of age.
Anyone can get meningococcal disease. But it is most
common in infants less than one year of age and people
with certain medical conditions, such as lack of a
spleen. College freshmen who live in dormitories, and
teenagers 15-19 have an increased risk of getting
meningococcal disease.
Meningococcal vaccine is also recommended for other
people at increased risk for meningococcal disease:
Meningococcal infections can be treated with drugs
such as penicillin. Still, about 1 out of every ten people
who get the disease dies from it, and many others are
affected for life. This is why preventing the disease
through use of meningococcal vaccine is important for
people at highest risk.
• U.S. military recruits.
2
Meningococcal vaccine
There are two kinds of meningococcal vaccine in the U.S.:
- Meningococcal conjugate vaccine (MCV4) was
licensed in 2005. It is the preferred vaccine for
people 2 through 55 years of age.
- Meningococcal polysaccharide vaccine (MPSV4)
has been available since the 1970s. It may be used if
MCV4 is not available, and is the only meningococcal
vaccine licensed for people older than 55.
Both vaccines can prevent 4 types of meningococcal
disease, including 2 of the 3 types most common in the
United States and a type that causes epidemics in
Africa. Meningococcal vaccines cannot prevent all
types of the disease. But they do protect many people
who might become sick if they didn’t get the vaccine.
This dose is normally given during the routine preadolescent immunization visit (at 11-12 years). But
those who did not get the vaccine during this visit
should get it at the earliest opportunity.
• College freshmen living in dormitories.
• Microbiologists who are routinely exposed to
meningococcal bacteria.
• Anyone traveling to, or living in, a part of the world
where meningococcal disease is common, such as
parts of Africa.
• Anyone who has a damaged spleen, or whose spleen
has been removed.
• Anyone who has terminal complement component
deficiency (an immune system disorder).
• People who might have been exposed to meningitis
during an outbreak.
MCV4 is the preferred vaccine for people 2 through 55
years of age in these risk groups. MPSV4 can be used if
MCV4 is not available and for adults over 55.
How Many Doses?
People 2 years of age and older should get 1 dose.
Sometimes a second dose is recommended for people
who remain at high risk. Ask your provider.
MPSV4 may be recommended for children 3 months to
2 years of age under special circumstances. These
children should get 2 doses, 3 months apart.
4
Some people should not get
meningococcal vaccine or
should wait
• Anyone who has ever had a severe (life-threatening)
allergic reaction to a previous dose of either
meningococcal vaccine should not get another dose.
• Anyone who has a severe (life threatening) allergy to
any vaccine component should not get the vaccine.
Tell your provider if you have any severe allergies.
• Anyone who is moderately or severely ill at the time
the shot is scheduled should probably wait until they
recover. Ask your provider. People with a mild illness
can usually get the vaccine.
• Anyone who has ever had Guillain-Barré Syndrome
should talk with their provider before getting MCV4.
• Meningococcal vaccines may be given to pregnant
women. However, MCV4 is a new vaccine and has
not been studied in pregnant women as much as
MPSV4 has. It should be used only if clearly needed.
• Meningococcal vaccines may be given at the same
time as other vaccines.
5
What are the risks from
meningococcal vaccines?
A vaccine, like any medicine, could possibly cause
serious problems, such as severe allergic reactions. The
risk of meningococcal vaccine causing serious harm,
or death, is extremely small.
Mild problems
As many as half the people who get meningococcal
vaccines have mild side effects, such as redness or pain
where the shot was given.
If these problems occur, they usually last for 1 or 2 days.
They are more common after MCV4 than after MPSV4.
A small percentage of people who receive the vaccine
develop a fever.
Severe problems
• Serious allergic reactions, within a few minutes to
a few hours of the shot, are very rare.
• A serious nervous system disorder called GuillainBarré Syndrome (or GBS) has been reported among
some people who received MCV4. This happens so
rarely that it is currently not possible to tell if the
vaccine might be a factor. Even if it is, the risk is
very small.
Meningococcal
1/28/08
Vaccine Information Statement (Interim)
6
What if there is a moderate or
severe reaction?
What should I look for?
• Any unusual condition, such as a high fever,
weakness, or behavior changes. Signs of a serious
allergic reaction can include difficulty breathing,
hoarseness or wheezing, hives, paleness, weakness, a
fast heart beat or dizziness.
What should I do?
• Call a doctor, or get the person to a doctor right away.
• Tell your doctor what happened, the date and time
it happened, and when the vaccination was given.
• Ask your doctor, nurse, or health department to
report the reaction by filing a Vaccine Adverse
Event Reporting System (VAERS) form.
Or you can file this report through the VAERS web
site at www.vaers.hhs.gov, or by calling
1-800-822-7967.
VAERS does not provide medical advice.
7
The National Vaccine Injury
Compensation Program
A federal program exists to help pay for the care of anyone who has had a rare serious reaction to a vaccine.
For information about the National Vaccine Injury
Compensation Program, call 1-800-338-2382 or visit
their website at www.hrsa.gov/vaccinecompensation.
8
How can I learn more?
• Ask your doctor or nurse. They can give you the
vaccine package insert or suggest other sources of
information.
• Call your local or state health department.
• Contact the Centers for Disease Control and
Prevention (CDC):
- Call 1-800-232-4636 (1-800-CDC-INFO)
- Visit CDC’s National Immunization Program
website at www.cdc.gov/vaccines
- Visit CDC’s meningococcal disease website at
http://www.cdc.gov/meningococcal/
- Visit CDC’s Travelers’ Health website at
wwwn.cdc.gov/travel
department of health and human services
Centers for Disease Control and Prevention
Student Medical Form
Please print in black ink. To be completed by student.
Last Name
First Name
Middle Name
Permanent Address
City
Gender:
State
Male
Female
Banner ID#
Date of Birth
Zip Code
Marital Status:
Phone Number
S
M
Other
Email Address
Class you are entering (circle):
Fr.
So.
Jr.
Sr.
Previously Enrolled Here? (circle):
Grad.
Yes
No
Semester Entering (circle):
Fall
Spring
Summer 1
Other
Year 20___
Summer 2
Name of Person to Contact in Case of Emergency
Relationship
Address
City
State
Zip Code
Phone Number
The following health history is confidential, does not affect your admission status, and, except in an emergency situation or by court order, will not be released without
your written permission. Please attach additional sheets for any items that require further explanation.
Family & Personal Health History
Please print in black ink. To be completed by student.
Has any person, related by blood, had any of the following?
Yes
No
Relationship
Yes
No
Relationship
Yes
High blood pressure
Cholesterol or blood fat disorder
Cancer
Stroke
Diabetes
Type:
Heart attack before age 55
Glaucoma
Psychiatric illness
Blood or clotting disorder
Alcohol/Drug Problems
Suicide
No
Relationship
Have you ever had or have you now? (Please check the appropriate column to the right of each item and, if yes, indicate the year of first occurrence.)
Yes
No
Year
Yes
No
Year
Yes
No
Year
Yes
High blood pressure
Hay fever
Jaundice or hepatitis
Kidney stones
Rheumatic fever
Allergy injection therapy
Protein or blood in urine
Heart trouble
Arthritis
Pain or pressure in chest
Concussion
Frequent or severe
headache
Rectal disease
Severe or recurrent
abdominal pain
Hernia
Easy fatigability
Severe menstrual cramps
Shortness of breath
Asthma
Dizziness or fainting spells
Pneumonia
Severe head injury
Chronic cough
Paralysis
Head or neck radiation
treatments
Tumor or cancer
No
Year
Hearing loss
Sinusitis
Anemia or sickle cell
anemia
Eye trouble besides
corrective lenses
Bone, joint, or other
deformity
Irregular periods
Sexually transmitted
disease
Blood transfusion
Disabling depression
Knee problems
Alcohol use
Excessive worry or anxiety
Recurrent back pain
Drug use
Specify:
Ulcer
Neck injury
Malaria
Specify: (duodenal or stomach)
Back injury
Thyroid trouble
Intestinal trouble
Broken bone
Anorexia/bulimia
Smoke 1+ pack
cigarette/week
Regularly exercise
Diabetes
Pilonidal cyst
Specify:
Wear seat belt
Serious skin disease
Frequent vomiting
Kidney infection
Other (Specify):
Mononucleosis
Gallbladder trouble or
gallstones
Bladder infection
Other (Specify):
Please list any drugs, medicines, birth control pills, vitamins and minerals (prescription and nonprescription) you use and how often you use them.
Name
Use
Dosage
Name
Use
Dosage
Name
Use
Dosage
Name
Use
Dosage
Name
Use
Dosage
Name
Use
Dosage
Name
Use
Dosage
Name
Use
Dosage
Revised 7/2012
Student Medical Form
Please print in black ink. To be completed by student.
Check each item “Yes” or “No”. Every item checked “Yes” must be fully explained in the space to the right, or on an attached sheet. Have you ever experienced any
adverse reactions (hypersensitivities, allergies, upset stomach, rash, hives, etc.) to any of the following? If yes, please explain fully the type of reaction, your age when
the reaction occurred, and if the experience has occurred more than once.
Adverse Reactions to:
Yes
No
Explanation
Penicillin
Sulfa
Other antibiotics(name):
Aspirin
Codeine
Other pain relievers
Other drugs, medicines, chemicals
(specify):
Insect bites
Food allergies (name):
Yes
No
Explanation
Do you have any conditions or disabilities that
limit your physical activities? (If yes, please
describe)
Have you ever been a patient in any type of
hospital? (Specify when, where, and why)
Has your academic career been interrupted due
to physical or emotional problems? (Please
explain)
Is there loss or seriously impaired function of any
paired organs? (Please describe)
Other than for a routine checkup, have you seen
a physician or healthcare professional in the past
six months? (Please describe)
Have you ever had any serious illness or injuries
other than those already noted? (Specify when
and where and give details)
Important Information
Please read and complete.
Statement by Student (Or Parent/Guardian, if Student is Under Age 18):
(A) I have personally supplied (reviewed) the above information and attest that it is true and complete to the best of my knowledge. I understand that
the information is strictly confidential and will not be released to anyone without my written consent, unless otherwise permitted by law. If I should be
ill or injured or otherwise unable to sign the appropriate forms, I hereby give my permission to the institution to release information from my
(son/daughter’s) medical record to a physician, hospital, or other medical profession involved in providing me (him/her) with emergency treatment
and/or medical care.
(B) I hereby authorize any medical treatment for myself (my son/daughter) that may be advised or recommended by the physicians of the Student
Health Service.
(C) I am aware that the Student Health Service charges for some services and I may be billed through the University Cashier if the account is not paid at
the time of visit. I accept personal responsibility for settling the account with the Cashier and for payment of incurred charges. I am responsible for
filing outpatient charges with insurance and acknowledge that my responsibility to the university is unaffected by the existence of insurance coverage.
Signature of Student
Date
Signature of Parent/Guardian, if student is under age 18
Date
Relationship to Student___________________________________________
Revised 7/2012
PHYSICAL EXAMINATION
A physical examination is required. This form must be completed in black ink and signed by a Physician, Nurse Practitioner or Physician Assistant.
Provider, please take a moment to counsel the future college student on lifestyle and social issues associated with the college experience.
Last Name
First Name
Permanent Address
Height
Vision:
Weight
Corrected
Uncorrected
Right 20/
Right 20/
Middle Name
DOB (mo/day/yr)
City
Zip Code
State
TPR
/
Left 20/
Left 20/
Color vision, if required
Hearing: (gross)
(15ft.)
Banner ID #
Area Code Phone #
BP
/
Urinalysis:
Sex
/
Sugar
Albumin
Micro, if indicated
Hgb or Hct
Right
Right
Left
Left
Please note immunization requirements listed on page 3. Chest x-ray is required if PPD is not given or if PPD is >5mm for recent household
contact of known case or if >10mm otherwise.
NORMAL
ABNORMAL
NOT DONE
EXPLAIN ABNORMALITIES
General Appearance
Head, Ears, Nose, Throat, Neck
Eyes
Respiratory
Cardiovascular
Mammary
Gastrointestinal
Hernia
Genitourinary
Musculoskeletal
Metabolic / Endocrine
Neuropsychiatric
Skin
A.
Is there loss or seriously impaired function of any organs?
Explain
No
If yes
B.
Is student under treatment for any medical or emotional condition?
Explain
No
If yes
C.
Recommendation for physical activity (physical education, intramurals, etc.)
Specify limitations
Unlimited
D.
Is student physically, mentally and emotionally healthy?
Explain
If no
Yes
If limited
**Only for Student Admitted to a Health Sciences Program**
Based on my assessment of the student’s physical and emotional/mental health on
participate in the activities of a health professional in a clinical setting.
Yes
, he/she appears able to
If no, explain
Signature of Physician, Nurse Practitioner, or Physician Assistant
Date
Print Name of the above Examiner
(Area Code) Phone Number
Fax Number
Office Address
City
State
Zip Code
NOTES
A.H. Ray Student Health Center
601 Martin Luther King Jr. Drive, RM 244
Winston-Salem, NC 27110