ON CAMPUS HOUSING HEALTH FORM
PART I – REPORT OF MEDICAL HISTORY
NOTE: Please complete (type or print all sections.) International students: please provide all health documents translated into English.
NAME: ___________________________________________________
last
first
middle
NCC ID# __________________
DATE OF BIRTH:
HOME ADDRESS:
___/___/___ (mon/day/yr)
____________________________________
Email address ______________________________
___________________________________________
City or town
state
zip country
TELEPHONE (
) ___________________________________
SEX:  F  M
SEMESTER SCHEDULE: Fall
□
Spring
□
Summer
□
Year______
Major or Program of Study ________________________________________
I. EMERGENCY CONTACT
Name of Contact __________________________________________
Address __________________________________________________
Phone (
) ______________________________________________
Relationship ____________________________________
City __________________State _______ Zip _________
Business Phone (
) ____________________________
MEDICAL HISTORY – Please answer yes or no to all questions and insert the year for all positive answers:
Yes
No
If Yes, Explain
Allergies
_____ _____
________________________________________________________________________
Asthma
_____ _____
________________________________________________________________________
Cardiac
_____ _____
________________________________________________________________________
Chemical Dependency
_____ _____
________________________________________________________________________
Drugs
_____ _____
________________________________________________________________________
Alcohol
_____ _____
________________________________________________________________________
Diabetes Mellitus
_____ _____
________________________________________________________________________
Gastrointestinal Disorder _____ _____
________________________________________________________________________
Hearing Disorder
_____ _____
________________________________________________________________________
Hypertension
_____ _____
________________________________________________________________________
Neuromuscular
_____ _____
_______________________________________________________________________
Orthopedic Condition
_____ _____
________________________________________________________________________
Respiratory Illness
_____ _____
________________________________________________________________________
Seizure Disorder
_____ _____
_______________________________________________________________________
Vision Disorder
_____ _____
________________________________________________________________________
Other (Specify)
_____ _____
________________________________________________________________________
II.
ACCIDENT AND HEALTH INSURANCE ~ Required for On Campus Housing
Please submit a front and back copy of your health insurance card for the Health & Wellness Center. All
residents must have health insurance. Note: The college automatically enrolls all resident students into the
college resident health insurance plan upon registration for classes. In order to waive this insurance coverage
and have the charge removed from your tuition bill, you must complete the online waiver on an annual basis.
Submission of a private health insurance card to the Health & Wellness Center will NOT waive the college’s
insurance charge. More information regarding student insurance and waiver is provided under separate cover.
Choose one: I have private health insurance:
I accept school insurance: ____
If the above named emergency contact cannot be reached at the time of an emergency, the College is authorized to send the above
named student to the nearest hospital and/or to administer necessary emergency care. I also authorize the release of information
regarding my health/medical status to the Northampton Community College Health Services Center, to the Residence Hall Director, to
the appropriate health care agency in which I am completing clinical requirements, and to the above named emergency contact.
Signature ___________________________________
Student signature (if 18 years of age or over)
Rev FA15
_________________________________
Parent’s signature (if student is under 18)
_____________
Date
Page 1
PART II – REPORT OF MEDICAL EXAMINATION BY PHYSICIAN
ON-CAMPUS HOUSING HEALTH FORM
An examination by a Physician is REQUIRED. Living on Campus is PROHIBITED until the required medical forms are
received and approved by the Director of the College Health and Wellness Center.
Name _____________________________________________________________
First
Middle
Last
I.
Height __________ Weight _____________ Blood Pressure ______________________ Pulse _______________
II. Vision
III.
NCC STUDENT ID#_____________
Uncorrected
Corrected
R _______ L _______
R _______ L _______
Clinical Examination - Describe details of abnormalities
Date of Examination____________________________________
Normal
Abnormal
Comments
Skin
Head and scalp
Eyes
Ears/Hearing
Mouth, Nose, Throat
Neck
Heart
Lungs
Abdomen
Genitourinary
Musculoskeletal
Neurological
PLEASE INDICATE ANY PHYSICAL RESTRICTION______________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
MEDICATION ALLERGIES___________________________________________________________________________________
____________________________________________________________________________________________________________
MEDICATIONS TAKEN ON A REGULAR BASIS_________________________________________________________________
____________________________________________________________________________________________________________
This student is medically cleared to participate in Intercollegiate Athletics
Yes
No
Note to Physician: Please complete pages 3 and 4 regarding immunizations and tuberculosis assessment with
student.
Please print, type or stamp: Name of Family Physician _______________________________________________________________
Address ______________________________________________________________________________
Phone ______________________________________________________________________________
Signature of Physician __________________________________________________ Date ____________
PLEASE SUBMIT COMPLETED FORMS by mail or fax:
Rev FA15
To the College Health and Wellness Center
Northampton Community College
3835 Green Pond Road, Bethlehem PA 18020
Phone (610) 861-5365, FAX (610) 861-4545
Page 2
ON-CAMPUS HOUSING HEALTH FORM
IMMUNIZATIONS AND TESTS
Name _____________________________________________________________
Last
first
middle
DATE OF BIRTH: ___/___/___
m d yr
NCC STUDENT ID#_____________
Sex:
Male
□
Female
□
Enter Month, Day, & Year Each
Immunization Was Given
DOSES
REQUIRED VACCINES
Tetanus, diphtheria and pertussis
(Must be within 10 years)
Tdap
/
Hepatitis B (recommended)
1
/
/
2
/
/
Varicella (Chickenpox)
1
/
/
2
/
/
Measles, Mumps, Rubella (MMR)
1
/
/
2
/
Meningococcal Vaccine
Date Received _________________
/
3
/
/
Or year when you had disease
/
2
/
/
IF RECORDS OF THE ABOVE VACCINATIONS CANNOT BE OBTAINED,
SUBMIT BLOOD TITERS TO DOCUMENT IMMUNITY
TUBERCULOSIS (TB) SCREENING/TESTING:
Please answer the following questions:
Have you ever had a positive TB skin test?
Yes ____ No ____
Have you ever had close contact with anyone who was sick with TB? Yes ____ No ____
Were you born in a country other than the U.S. If yes, give the name of the country. Yes ____ No ____
Country________________________________
Have you arrived in the U.S. within the past 5 years? Yes ____ No ____
Have you ever traveled* to/in another country(ies)? Yes ____ No ____ Name the country(ies).
______________________________________________________________________________________________
Have you ever been vaccinated with BCG, a vaccine to prevent tuberculosis?
Yes ____ No ____
* The significance of the travel exposure should be discussed with a health care provider or call the NCC Health & Wellness Center.
If the answer is YES to any of the above questions, Northampton Community College requires that a health care
provider complete a tuberculosis risk assessment or a TB skin test (to be completed within 6 months prior to the
start of classes). See page 4 for relevant form.
If the answer to ALL of the above questions is NO, no further testing or further action is required.
PLEASE SUBMIT COMPLETED FORMS by mail or fax:
Rev FA15
To the College Health and Wellness Center
Northampton Community College
3835 Green Pond Road, Bethlehem PA 18020
Phone (610) 861-5365, FAX (610) 861-4545
Page 3
TUBERCULOSIS RISK ASSESSMENT BY HEALTH CARE PROVIDER
RESULTS OF A TUBERCULIN SKIN TEST (DONE WITHIN 6 MONTHS OF START OF SCHOOL)
Tuberculin
Tests Date
Applied
Date Read
Arm
Device
Antigen
Results (mm)
Manufacturer
Signature
Signature
If the Mantoux tuberculin skin test (TST) is positive or the student had a previous positive TST,
then an Interferon Gamma Release Assay (IGRA) test or a chest X-ray should be done
OR
TUBERCULOSIS SYMPTOM CHECK
Y____N____
Y____N____
Y____N____
Y____N____
Y____N____
Y____N____
Y____N____
Unexplained weight loss
Anorexia, loss of appetite
Fever
Night sweats
Productive cough lasting longer than three weeks
Coughing up blood (hemoptysis)
Chest pain
If you answered “Yes” to any of the above statements, please explain __________________________________________
__________________________________________________________________________________________________
____________________________________________________________________________________________________
___________________________________________________________________________________________________________
Please print, type or stamp: Name of Family Physician _______________________________________________________________
Address ______________________________________________________________________________
Phone ______________________________________________________________________________
Signature of Physician __________________________________________________ Date ___________
PLEASE SUBMIT COMPLETED FORMS by mail or fax:
Rev FA15
To the College Health and Wellness Center
Northampton Community College
3835 Green Pond Road, Bethlehem PA 18020
Phone (610) 861-5365, FAX (610) 861-4545
Page 4