IMM Compliance Noncompliance -for office use only

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Student Health Services
Wichita State University
1845 Fairmount
209 Ahlberg Hall
Wichita, KS 67260-0092
(316) 978-3620
IMM
Compliance
Noncompliance
-for office use only-
CONFIDENTIAL HEALTH HISTORY FORM
Date:
Have you previously used WSU Student Health Services?
Yes
Last Name
Middle
First
Wichita Address
No
Wichita Phone
My WSU ID#
Date of Birth
Sex
Race
EMERGENCY CONTACT INFORMATION:
Name:
Relationship:
Address:
Home Phone:
Business Phone:
MEDICAL HISTORY Do you have a present or past history of: (check all that apply)
Alcohol abuse
Disability/handicap*
High blood pressure
Rheumatic fever
Anemia
Drug abuse
Intestinal/Stomach Prob.
Rubella (3 day measles)
Arthritis
Ear trouble/hearing loss
Joint disease/injury
Scarlet fever
Asthma
Eating disorder
Measles, red
Seizures
Back problems
Eye disease/problems
Menstrual problems
Sexually trans. dis (STD)
Cancer
Gallbladder trouble
Migraine headaches
Sickle Cell Trait/Anemia
Chickenpox
Hay fever (recurrent)
Mononeucleosis (Mono)
Sinus trouble
Colitis
Head injury
Mumps
Skin problems (chronic)
Convulsions
Headache (recurrent)
Pneumonia
Sleep problems
Cough (chronic)
Heart disease/problems
Paralysis
Spleen, surgical removal
Depression
Hepatitis/Jaundice
Polio
Thyroid disease
Diabetes
Hernia/rupture
Psychological counseling
Tuberculosis
Urinary Tract Infection
Other:
*Describe handicap/disability:
Do you use tobacco products? (Pipe, cigar, cigarettes or chewing tobacco)
Yes
No
Stop Date
Medications: (list all, including birth control):
Drug Allergies:
Allergies: (latex, tape, food, others):
Hospitalizations/Surgeries:
Please complete the back of this form.
Rev 06/04 , 01/06, 09/07, 08/08
Wichita State University Student Health Services Medical History/Immunization Form
1. Were you born before January 1, 1957?
If yes, skip to question # 4.
Yes
No
7. Date of 1st Hepatitis B Vaccine
/
month/year
2. Date of first measles, mumps
& rubella (MMR) vaccine
/
month/year
Date of 2nd Hepatitis B Vaccine
/
month/year
3. Date of 2nd MMR
/
month/year
Date of 3rd Hepatitis B Vaccine
/
month/year
8. Date of 1st Varicella (chickenpox)
vaccine
/
month/year
4. Date of most recent Tetanus diphtheria
/
vaccination (Td/DTP,DtaP or Tdap) month/year
5. Date of completion of 4th Polio
vaccination (OPT or IPV)
Date of 2nd Varicella vaccine
/
month/year
/
month/year
6. Date of last tuberculin (PPD) test
Must be within past year.
Was test reading >9 mm or Positive?
/
month/year
___Yes___No
/
month/year
Are you currently living in a Residence Hall? Yes / No
Was Chest X-ray done?
___Yes___No
Will you be living in a University Residence Hall?
Yes /No
(Required for first time residents of a University
Residence Hall.)
See WSU Policy 8.14 attached
Results of X-ray
Normal
Abnormal
(May be required to bring x-ray film or report.)
Per WSU policy 8.15 attached, a tb skin test must be
done at Student Health Services prior to enrolling in
classes. Contact Student Health for tb testing times.
9. Date of Meningitis vaccine
Incomplete vaccination or TB testing? If you have not
had or completed the vaccinations for measles, mumps
rubella; tetanus or polio, or have not had a TB test, please
mark this box.
Incomplete
Comments:
If complete, leave blank.
A copy of your immunization record must be
attached to this form before returning to Student
Health.
Comments:
Family History
Alcohol/Drug Abuse
(place relationship in blank)
Death before 50
Elevated Cholesterol
Hypertension/Stroke
Cancer/type
Diabetes
Heart Disease
Mental Illness
Other:
I hereby certify this history is complete and accurate to the best of my knowledge.
Signature
Date
My WSU ID # or last 4 digits of Social Security #
If under 18 years of age, signature of Parent/Guardian and student is required.
Signature
Date
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