2015 – 2016
MCU Medical Information
Marymount California University is committed to creating and supporting a healthy academic community. We
respect and adhere to all HIPPA protected regulations regarding each student’s health and medical records.
We recognize that varying academic programs in multi-sites may offer different levels of medical service.
Based on the services provided, varied medical information is needed.
Section 1: Student Information and Emergency Contact
 Required for all students at all sites.
 Completed by student.
 If student under the age of 18, must be signed by parent/guardian.
 This information is not Confidential and will be shared with MCU departments as necessary
Section 2: Immunizations
 Required for all students at all sites.
 Completed by medical provider (nurse practitioner, physician’s assistant, or medical doctor).
Section 3: Medical History
 Required for all students attending Southern California programs with access to Student Health Center.
 Completed by student.
Section 4: Physical Exam
 Required for all students attending Southern California programs with access to Student Health Center.
 Completed by medical provider (nurse practitioner, physician’s assistant, or medical doctor).
Scan, fax, or mail completed documents to the Student Health Center.
Fall Deadline: July 15.
Spring Deadline: December 1st.
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Direct Fax #: (310) 265 – 9231
Email: Judith Hotchkiss, R.N., C, Director: jhotchkiss@marymountcalifornia.edu
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Dianne Bettis, Administrative Assistant dbettis@marymountcalifornia.edu
Phone Number: (310) 303-7244
Mail:
or
Student Health Center
Marymount California University
30800 Palos Verdes Dr. East
Rancho Palos Verdes, CA 90275
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Section 1: Student Information and Emergency Contact
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Required for all students at all sites.
Completed by student.
If student under the age of 18, must be signed by parent/guardian.
This information is not confidential and will be shared with MCU departments as necessary
PLEASE TYPE OR PRINT THE FOLLOWING IN BLACK INK AND IN THE ENGLISH LANGUAGE.
Name: __________________________________________________________________________________________
LAST
FIRST
MIDDLE INITIAL
Date of Birth: ____/____/_________ Student ID Number: ________________________
 Male  Female
In order to assure prompt treatment, particularly in emergencies, the following information should be specific and
current.
MEDICAL EMERGENCY INFORMATION
A. Allergies to the following drug(s):
_______________________________
_____________________________
_____________________________
B. Takes the following medication(s):
Medication
Dosage
_______________________________
_____________________________
Reason
_____________________________
_______________________________
_____________________________
_____________________________
_______________________________
_____________________________
_____________________________
C. Has had the following serious illness(es) or operation(s):
___________________________________________________________________________________________
_________________________
___
D. Date of the most recent tetanus booster: _______/_______/____________
Month
Day
Year
E. EMERGENCY CONTACT INFORMATION:
This information is not confidential and will be shared with MCU departments as necessary
NAME: __________________________________________________
Home Phone: ______________________________
Relationship To Student:________________
Cell Phone: _______________________________________
Home Address: ___________________________________________________________________________________
City/ State/ Zip/ Country: ____________________________________________________________________________
NAME: ___________________________________________________ Relationship to Student:_________________
Home Phone: _____________________________
Cell Phone:__________________________________________
Home Address: ___________________________________________________________________________________
City/ State/ Zip/ Country: ____________________________________________________________________________
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F. INSURANCE CARRIER
Company Name: ___________________________________________ Policy Number: ________________________
Company Phone Number:____________________________________
Address: _________________________________________________________________________________________
City/ State/ Zip/ Country: _____________________________________________________________________________
IN CASE OF EMERGENCY
I hereby grant Marymount California University the following permission:
1. In case of ordinary illness in Southern California, care will be dispensed through the Student Health
Center at the Oceanview Campus.
2. In case of serious illness, accident or after hours, students will be referred to Urgent Care, Private
Physician, ER or Emergency Response Services will be called.
3. In case of serious illness or accident please complete the following if you would like your private
physician to be contacted.
PHYSICIAN’S NAME: _______________________________ Telephone: ____________________
Address: ____________________________________________________________________________
City/ State/ Zip: ______________________________________________________________________
III.
RELEASE OF LIABILITY STATEMENT
Marymount California University will NOT assume responsibility for any student’s medical or surgical
expenses incurred while attending the institution.
My Signature implies that I understand the above _______________________________Date:_____________________
IV.
PARENTAL/ GUARDIAN PERMISSION FOR TREATMENT
If you are under the age of 18, your parent/guardian is REQUIRED to sign below.
I, the undersigned, legal guardian of _______________________________________________, minor, do
hereby consent
Print Student’s Full Legal Name
to any X-ray, examination, anesthetic, medical or surgical diagnosis or treatment and hospital service that
may be rendered to the minor, under the instructions of the Marymount California University Student Health
Center or an attending physician, whether such diagnosis or treatment is rendered at the office of the
physician or at the hospital licensed by the State of California. This consent is given in the advance to
encourage the staff at the Marymount Student Health Center, attending physicians or hospital(s) to exercise
their best judgment so as to provide prompt medical service to the minor.
Signature of Parent/Legal Guardian:________________________________________________________
Print Name of Parent/Legal Guardian:______________________________________________________
Date:___________________________________
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Section 2: Immunizations - Confidential
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Required for all students at all sites.
Completed by medical provider (nurse practitioner, physician’s assistant, or medical doctor).
Name___________________________________________________________________________________________
(Last)
(First)
Date of Birth___/___/___
□ Male
□ Female
TO BE COMPLETED BY HEALTHCARE PROVIDER ONLY
PART 1: REQUIRED IMMUNIZATIONS
TETANUS-DIPTHERIA-PERTUSSIS(Tdap): Primary Series AND Tdap booster after age 11
Date Tdap booster given: ___/___/___ (Within last 10 years)
MEASELS- MUMPS-RUBELLA (M.M.R.):
1ST Dose: ___/___/___ 2nd Dose: ___/___/___, OR positive titer: ___/___/___
HEPATITIS B:
1ST Dose: ___/___/___ 2nd Dose: ___/___/___ 3rd Dose: ___/___/___, OR positive titer: ___/___/___
PART 2: T.B. SKIN TEST OR CHEST X-RAY – Within 1 year
Date of Test _______________ Date of Reading _______________ Results ______________________
For Chest X-ray, please attach copy of result report
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
PART 3: RECOMMENDED VACCINES
MENINGOCOCCAL:
1st Dose: ___/___/___ 2nd Dose: (If applicable) ___/___/___
VARICELLA (Chicken Pox):
Year of disease: ______, OR
1st Dose:___/___/___ 2nd Dose___/___/___, OR positive titer: ___/___/___
HEPATITIS A:
1st Dose: ___/___/___ 2nd Dose: ___/___/___
HPV:
1st Dose: ___/___/___ 2nd Dose: ___/___/___
3rd Dose: ___/___/___
_______________________________________________________________________________________________
Name of Provider
License Number
_______________________________________________________________________________________________
Signature of Provider
Date
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Meningitis Signature Form - Confidential
As Director of the Student Health Center at Marymount California University, I am writing to inform you about the meningococcal
disease, a rare, but potentially fatal bacterial infection commonly referred to as meningitis and a new immunization
recommendation that may affect your college-bound student.
The U.S. Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices (ACIP) and the American
College Health Association (ACHA) have approved new recommendations that urge all first-year students living in residence halls to
be immunized against the meningococcal disease. The ACIP and ACHA recommendations further state that other college students
under 25 years of age, who choose to reduce their risk for the disease, may choose to be vaccinated.
Although Marymount California University does not require students to be immunized against meningitis for admission to the
university, we highly recommend that all students receive the Menactra conjugate vaccine, a reformulated meningococcal vaccine
(“conjugate”) that has the potential to provide longer duration of protection against four of the five strains (or types) of bacteria that
cause meningococcal disease— types A, C, Y, and W-135.
The meningococcal disease strikes 1,400 to 3,000 Americans each year and is responsible for approximately 150 to 300 deaths.
Adolescents and young adults account for nearly 30 percent of all cases of meningitis in the United States. In addition, approximately
100 to 125 cases of meningococcal disease occur on college campuses each year, and 5 to 15 students die as a result. Meningococcal
infection is contagious and progresses very rapidly. It can easily be misdiagnosed as the flu, and if not treated early, meningitis can
lead to death or permanent disabilities. One in five of those who survive, suffer from long-term side effects, such as brain damage,
hearing loss, seizures or limb amputation.
Due to lifestyle factors, such as crowded living situations, bar patronage, active or passive smoking, irregular sleep patterns and sharing
of personal items, college students living in residence halls are at the highest risk to acquire meningitis than the general college
population.
For more information, please feel to contact the Student Health Center and/or consult your physician. You can also find information
about the disease and immunization by visiting the ACHA website at www.acha.org/meningitis and the CDC website at
www.cdc.gov/ncidod/diseases/submenus/sub_meningitis.htm.
Judith Hotchkiss, R.N., C.
Student Health Center, Director
All colleges and universities, including Marymount California University, urge all students (especially those who plan to
live in the College Residences) to receive the meningococcal vaccine.
I have reviewed the above information and: (Please check one of the following that applies to you and then sign below):
____ I intend to receive the meningococcal vaccine:
____ at my private physician’s office.
____ at the Marymount Student Health Center.
(A fee of $105 will apply to receive the vaccine at the Student Health Center.)
____
I do not intend to receive the meningococcal vaccine.
____
I have received the meningococcal vaccine.
Verification by Physician 1st Dose: ___/___/___ 2nd Dose (If applicable) ___/___/___
Physician Signature:_____________________________________________________
Student Signature:___________________________________________________
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Date_____/_____/________
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Section 3: Medical History - Confidential
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Student Name__________________________________
Required for all students attending Southern California programs with access to Student Health Center.
Completed by student.
FAMILY HISTORY
Has any parent, grandparent or sibling had any of the following?
Yes
No
Yes
High blood pressure
___ ___ Migraines
____
No
____
Anemia
___
___
Problem drinker
____
____
Blood disorder
___
___
Drug User
____
____
Epilepsy
___
___
____
____
Ulcers
___
___
Unexplained
death
Mental illness
____
____
Allergy, asthma
___
___
Other
____
____
Age
Health Problems
Father
_______________________________
Mother
_______________________________
Brother(s)
_______________________________
_______________________________
Sister(s)
______________________________
______________________________
Stroke or heart attack ___ ___ Specify: ____________________
before age 55
___________________________
PERSONAL HISTORY
1. Have you ever had surgery?  Yes  No If yes, explain: ______________________________________________
______________________________________________________________________________________________
2. Have you ever been hospitalized?  Yes  No If yes, explain: ________________________________________
______________________________________________________________________________________________
3. Have you ever had any significant injuries or medical illnesses/conditions?  Yes  No If yes, explain:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
4. List any medications you are currently taking (include nonprescription drugs): _____________________________
______________________________________________________________________________________________
5. Are you allergic to any medications?  Yes  No If yes, list: __________________________________________
______________________________________________________________________________________________
6. Have you had an allergic reaction to any food, insect stings or other substances?  Yes  No If yes, explain:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
PSYCHOLOGICAL HISTORY
If you are currently seeing a psychologist, psychiatrist or therapist and would like to provide the information, please
complete the area below:
Therapist’s Name:_______________________________________
Telephone: ____________________________
Address: ________________________________________________________________________________________
City/ State/ Zip/ Country: ___________________________________________________________________________
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Section 4: Physical Exam - Confidential
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
Required for all students attending Southern California programs with access to Student Health Center.
Completed by medical provider (nurse practitioner, physician’s assistant, or medical doctor).
PLEASE TYPE OR PRINT THE FOLLOWING IN BLACK INK AND IN THE ENGLISH LANGUAGE.
Patient’s Name: _____________________________________________________________________________________
LAST
FIRST
Patient’s Date of Birth: _____/_____/______
MIDDLE INITIAL
Patient’s Gender (please check one):
 Male
 Female
Weight: ________
Height: ________
Blood Pressure: __________ LMP (women only): _____________
N
A
N
A
Head __________________________________________ Breasts ________________________________________
Eyes ___________________________________________ Heart __________________________________________
Ears ___________________________________________ Lungs __________________________________________
Nose __________________________________________ Abdomen ______________________________________
Throat _________________________________________ Genitalia _______________________________________
Teeth __________________________________________ Back __________________________________________
Neck __________________________________________ Extremities _____________________________________
Skin ___________________________________________ Neurological ____________________________________
Urine Dipstick Test: Date: _________________________________ Results: _________________________________
Chest X-ray (attach a copy of the report) OR T.B. Skin Test (must be within 1 year):
Date of T.B. test: _________________ Date of T.B. reading: _________________Results: __________________
CHRONIC CONDITIONS:
□ ADD/ADHD
□ Aspergers
□ Asthma
□ Autism
□ Depression/Anxiety
□ Diabetes
□ Eating Disorders
□ Severe Food Allergy
□ Other:____________________________________
__________________________________________
MEDICATION PRESCRIBED FOR ANY ABOVE CONDITION:
________________________________________
________________________________________________
________________________________________
________________________________________________
Abnormal findings/ comments:
Limitations of physical activity? _______________________________________________________________________
Impressions/ Remarks/ Recommendations: _____________________________________________________________
Provider’s Signature: ________________________________________________
Date of exam: __________________
Provider’s Name (print or stamp): ________________________________ Telephone: _________________________
Address: __________________________________________________________________________________________
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