Student Health Center
Special Programs Building
28 Westhampton Way
University of Richmond, VA 23173
Phone: 804-289-8064
wellness.richmond.edu
Student Name: ______________________
UR ID: ______________________________
2015-2016 HEALTH HISTORY RECORD
(Student Completes)
Deadline All Students: June 12, 2015
(Spring Semester Transfers - January 4, 2016)
Students with incomplete forms are blocked from housing on move-in day.
MAIL THE COMPLETED FORM TO: Student Health Center, Special Programs Building, 28 Westhampton Way,
University of Richmond, VA 23173
RECORDS RECEIVED BY SCAN OR FAX WILL NOT BE ACCEPTED.
Name _____________________________________________________________________________________________
Last
First
Date of Birth ____/___/____
Middle
Social Security #________________________
UR Student ID # _____________________
Permanent Address __________________________________________________________________________________
Street
City
State /Country
Zip Code
Country of Birth ____________________ Email ___________________________________________________________
(Please print clearly)
Home Phone ___________________________ Student’s Cell ________________________________________________
Undergraduate _____
Law School _____
School of Continuing Studies _____
Incoming Class Status: 1st yr ___, 2nd yr. ____, 3rd yr. ___, 4th yr. ___
NCAA ATHLETE ____ SPORT ________
Although highly recommended, the University of Richmond does not require students to be covered by a medical insurance policy.
Is student covered by a medical insurance policy? Please circle: Yes or No
MEDICAL HISTORY
Yes No
□ □ ADD/ADHD
□ □ Allergies (annual/seasonal)
□ □ Anemia
□ □ Asthma/Exercise-Induced Asthma
□ □ Bone/Joint Disorder
□ □ Cancer
□ □ Chickenpox
□ □ Circulatory Problems/Blood Clots
□ □ Convulsions/Seizures/Epilepsy
Yes No
□ □ Diabetes
□ □ Eating Disorders
□ □ Mental Health Disorder
□ □ Gastrointestinal Problems
□ □ Gynecological Problems
□ □ Frequent Headaches
□ □ Heart Disease
□ □ Hepatitis/Liver Disease
□ □ HIV
Yes No
□ □ Kidney/Urinary Problems
□ □ Mononucleosis
□ □ Rheumatic Fever
□ □ Tuberculosis
□ □ Sexually Transmitted Disease
□ □ High Blood Pressure
□ □ Frequent Throat Infections
□ □ Frequent Ear Infections
□ □ Other – Explain Below
Remarks or Additional Information: _________________________________________________________________________________
______________________________________________________________________________________________________________
Allergies: medication/foods, etc (include reaction): ___________________________________________________________________________
Significant illness/hospitalization/surgery (include dates):
____________________________________________________________
______________________________________________________________________________________________________________
History of psychiatric/psychological disorder (include dates):
EMERGENCY CONTACT :
____________________________________________________________
Name:____________________________ Relationship: ________________________________________
Phone (list all): _______________________________________
Address: _________________________________________________
Page 1 of 4
Student Health Center
Special Programs Building
28 Westhampton Way
University of Richmond, VA 23173
Student Name:__________________
UR ID:___________________________
Student Cell Phone:_______________
TUBERCULOSIS RISK ASSESSMENT (TBRA)
Student Completes within 6 months of entrance to University
1. Have you ever had a positive tuberculosis (TB) test?
YES
NO
2. Were you born in one of the following areas?
YES
NO
Africa, Asia, Central America, Cuba, Dominican Republic, Eastern Europe, Haiti, India & other Indian
subcontinent nations, Mexico, Middle East (except Egypt, Israel, Jordan, Lebanon, Saudi Arabia,
UAE), Portugal, South America, South Pacific (except Australia & New Zealand).
3. Within the past 5 years, have you traveled to OR lived in any
YES
NO
of the following areas for more than one month?
Africa, Asia, Central America, Cuba, Dominican Republic, Eastern Europe, Haiti, India, & other Indian
subcontinent nations, Mexico, Middle East (except Egypt, Israel, Jordan, Lebanon, Saudi Arabia,
UAE), Portugal, South America, South Pacific (except Australia & New Zealand).
4. Do you have any of the following signs or symptoms of active TB disease?
YES
NO
Unexplained fever/chills for more than 1 week •unexplained fatigue •unexplained weight loss
•night sweats •cough with bloody sputum •persistent cough of unknown cause for more than 3 weeks.
5. Do any of the following situations apply to you?
YES
NO
•Close contact with a person known or suspected to have TB •use of any illegal injectable drug
•at risk for Human Immunodeficiency Virus (HIV) infection •history of solid organ transplant (kidney, heart, liver,etc)
•history of silicosis, diabetes, kidney disease, blood disorders or cancer, gastrectomy
• jejunoilieal bypass •chronic malabsorptive condition •low body weight (10% or more below ideal)
•volunteered, resided, or worked in a healthcare facility or congregate living setting (homeless shelter,
nursing home, or correctional facility) for longer than 1 month •on immunosuppressive therapy, such as
prolonged corticosteroid therapy, chemotherapy •on TNF-antagoinist medications (Humira, Embrel,
Remicade,etc)
IF YOU ANSWERED 'YES' TO ANY QUESTION ABOVE, TB TESTING IS REQUIRED
The Student Health Center (SHC) requires either the IGRA (Interferon Gamma Release Assay) Quantiferon Gold TB
test or the T-Spot TB test. PPD SKIN TESTS AND CHEST X-RAYS ARE NOT ACCEPTED IN LIEU OF THE IGRA.
Please select
one of the following options to complete your IGRA testing:
1.
Have the test done as soon as possible, prior to coming to the University. It may take several weeks for
the results, so do not delay testing. Submit a copy of the written report to the Student Health Center.
2.
Have the test done at the SHC during Orientation Week. The SHC will be open 8:30 am until 4:30 pm
Tuesday, August 18 through Friday, August 21. The charge for testing at the SHC is $75.00 which may be paid by
cash, check, SpiderCard, or placed on your Student Account.
3.
Students attending International Orientation: You will be scheduled for the test on Monday, August 17.
UR’s Office of International Education will provide information regarding your appointment time.
Student Signature:__________________________________________ Date: __________________
(or legal gaurdian if under age 18)
Page 2 of 4
Student Health Center
Special Programs Building
28 Westhampton Way
University of Richmond, VA 23173
Phone: 804-289-8064
Wellness.richmond.edu
Student Name:__________________
UR ID: _________________________
Date of Birth: ___________________
Student Cell Phone: ______________
2015-2016 IMMUNIZATION RECORD – Due June, 12, 2015
TO BE COMPLETED AND SIGNED BY YOUR HEALTH CARE PROVIDER
If vaccination dates are unavailable it is necessary to repeat the
vaccine or submit laboratory evidence of immunity (titer).
Virginia State Law and the University of Richmond Require the Following Immunizations
1) MMR (Measles, Mumps, Rubella)
Dose #1 _____/____/____
Two doses live vaccine required at or after 12 months of age, at least one month apart
Dose #2 _____/____/____
Use ONLY If vaccinated separately:
Measles
Dose #1 ____/____/____
Rubella
Dose #1 ____/____/____
Dose #2 ____/____/_____
Mumps
Dose #1 ____/____/____
Dose #2 ____/____/_____
2) TETANUS/DIPHTHERIA/PERTUSSIS (Tdap) or TETANUS/DIPTHERIA This booster date: _____/____/____must be within last 10
years. If this date is older than 10 years, revaccinate and attach documentation.
3) MENINGOCOCCAL VACCINE (ACYW-135) This booster date: _____/____/____ must be after student turns 16. If vaccine given
prior to 16th birthday, either revaccinate & attach documentation or sign waiver – see next page.
4) HEPATITIS B VACCINE
Dose #1 _____/____/____
(3 doses required)
Dose #2 _____/____/____
Dose #3 ____/____/____
(or sign waiver – see next page)
5) POLIO VACCINE
Last dose date:_____/_____/___ must be after student turns 4. If last dose given prior to 4th
birthday, sign waiver – see next page.
RECOMMENDED IMMUNIZATIONS
A. VARICELLA VACCINE- (STRONGLY RECOMMENDED)
Two doses of vaccine one month apart
OR History of Disease
Dose #1_____/____/____
Dose #2_____/____/____
____/____
B. HEPATITIS A VACCINE
2 doses vaccine given at 0, 6-12 months
Dose #1_____/____/____
Dose #2_____/____/____
C. HUMAN PAPILLOMAVIRUS VACCINE (HPV)
3 doses at 0, 2, and 6 month intervals
Dose #1_____/____/____
Dose #2_____/____/____
Dose #3_____/____/____
D. PNEUMOCOCCAL VACCINE (Type of Vaccine): PPSV23 ____ OR PCV13 ____
Dose #1 ____/____/____
➠Verified by :
Health Care Provider’s Signature
Name Printed
Address
Phone
Date
Page 3 of 4
WAIVER DOCUMENT
HEPATITIS B
Name: ____________________
HEPATITIS B is a serious infection of the liver caused by the Hepatitis B virus. The Hepatitis B virus (HBV) may
cause lifelong infection, cirrhosis of the liver, liver cancer, liver failure and death. Hepatitis B is transmitted
through infected body fluids such as blood, semen, and vaginal secretions; infection may occur through mucous
membranes and broken skin. Most commonly, Hepatitis B is transmitted by sexual contact. It may also be spread
by exposure to blood through contact sports, repeatedly sharing an infected person’s razor, toothbrush, or
earrings, travel to a high-risk area, use of illicit injectable drugs or through contaminated needles use for tattooing
or piercing. The Hepatitis B vaccine is safe and effective. The vaccine is generally a series of three doses given over
a period of 6 months, although the series never has to be re-started if the schedule is interrupted.
HEPATITIS B VACCINE WAIVER
I have reviewed the information provided on the risks associated with Hepatitis B disease, and the effectiveness of
any vaccine against Hepatitis B disease and I choose not to be vaccinated at this time.
Print Student’s Name: ________________________________ Date: _______________ Student Signature: __________________________________
(or Legal Guardian if under 18)
MENINGITIS
MENINGOCOCCAL DISEASE is a potentially fatal bacterial infection caused by the organism Neisseria
meningitis. Although meningococcal disease is relatively rare, the initial flu-like symptoms may make diagnosis
difficult. The disease may lead to brain damage, vital organ failure, permanent disability or death. Studies indicate
college students living in residence halls, especially freshmen residents, are at increased risk of infection.
MENINGOCOCCAL VACCINE WAIVER
I have reviewed the information provided on the risks associated with Meningococcal disease, and the effectiveness of any vaccine
against Meningococcal disease and I choose not to be vaccinated at this time.
Print Student’s Name: _______________________________________Date:____________ Student Signature: _______________________________________________
(or Legal Guardian if under age 18)
POLIO
POLIO is a highly contagious disease caused by a virus. The virus affects the nervous system and one in two
hundred cases leads to irreversible paralysis. There is no cure for polio; it may only be prevented by vaccination.
Polio vaccination has eradicated the disease from the US, but polio remains endemic in Afghanistan, Pakistan and
Nigeria and outbreaks continue to occur in some regions and countries*(see listing below). The Student Health
Center abides by the recommendations from the Centers for Disease Control and Prevention (CDC) if you
have not been previously vaccinated.
UNITED STATES RESIDENTS
18 YEARS OF AGE OR OLDER: Polio vaccine is not necessary or recommended, UNLESS you have plans to travel
to one of the countries listed below*. Please sign the Polio Vaccine Waiver.
UNDER 18 YEARS OF AGE: You must be vaccinated. Please send documentation of polio vaccination to the Student
Health Center.
FOREIGN-BORN
If you were born or reside in a country listed below* which has a high incidence of polio, 3 doses of vaccine are
required. Appropriate vaccination consists of two doses separated by 1-2 months, and a third dose 6-12 months
(6-month minimal interval). Please send documentation to the Student Health Center. If you were born or reside in
a country not listed below* and choose not to complete your polio vaccinations, please sign the Polio Waiver.
*Countries
Republic.
with High Incidence of polio: Afghanistan, Ethiopia, Iraq, Nigeria, Pakistan, Somalia, & Syrian Arab
POLIO VACCINE WAIVER
I have reviewed the information provided on the risks associated with polio disease and the effectiveness of polio vaccination.
I choose not to be vaccinated at this time.
Print Student’s Name: ______________________________________________Date:_____________________Student Signature:___________________________________
(or Legal Guardian if under 18)
Page 4 of 4