DO NOT STAPLE – KEEP RECORD IN ITS ORIGINAL ORDER – RETURN RECORD ONLY WHEN FULLY COMPLETE
Student Name:_______________________________________________________
Student ID:______________________
STUDENT HEALTH REPORTING FORM
Health Center
620 University Avenue, Selinsgrove, PA 17870-1001
Phone (570) 374-9164 / Fax (570) 372-2729
Health Center Webpage – http://www.susqu.edu/health
Counseling Center - Phone (570) 372-4751 / Fax (570) 372-2776
Athletic Department - Phone (570) 372-4270 / Fax (570) 372-2758
Information you provide will not be used to influence your situation at the university; it will be used solely as an aid to provide health
care while you are a student. In the future, medical information shared with the Health Center would be strictly for the use of the Health
Center; sharing of medical information will be governed by the enclosed HIPAA regulations. The above-named offices would not share
future information without the consent of the student.
Must be returned to the Health Center before July 15
or a hold will be placed on your registration, athletic participation, and/or your room key will be held.
SECTIONS I, II, and III TO BE COMPLETED BY STUDENT (PLEASE PRINT NEATLY IN BLACK INK)
Part I – PERSONAL DATA
Name:
Last
Date of Birth:
Month
/
First
Day
Semester you are entering (circle):
Fall
/
Middle
Social Security No.:
Year
Spring
-
Class you are entering (circle):
Previously enrolled at Susquehanna University (circle): No
Yes
-
FR
SO
JR
SR
If Yes, year(s) enrolled:
Sport(s) you plan on participating in at Susquehanna University:
Female
Male
Transgender
Marital Status:
Citizenship:
Religion:
Home Address:
No. & Street
Birth State:
City/Town
State
Zip
Country of Origin if other than United States:
Home Phone:
Student’s Cellular Phone:
In case of an emergency notify:
Name
Home Address
Family Physician:
Relationship
Home Phone
Cellular Phone
Business Phone
Phone:
Address:
1
DO NOT STAPLE – KEEP RECORD IN ITS ORIGINAL ORDER – RETURN RECORD ONLY WHEN FULLY COMPLETE
Student Name:_______________________________________________________
Student ID:______________________
Part II – FAMILY AND PERSONAL HISTORY
Do you have any known allergies? If so, please list:
Yes No Specify Allergy:
Drug
Food
Insect
Sting/Bite
Other
Epi Pen:
Has any person, related by blood, had any of the following:
Yes
No Relationship
Alcohol/Drug Problems
Blood or Clotting Disorder
Cholesterol or Blood Fat Disorder
Diabetes
Glaucoma
Heart Attack Before Age 55
High Blood Pressure
Psychiatric Illness
Stroke
Have you ever had or do you now have:
Yes
No
Yes
No
Relationship
Cancer – Specify Type:
Has any member of your family
died suddenly under the age of
50? If yes, cause of death:____
__________________________
Suicide
Other – Specify:
(please check at right of each item and if “yes”, indicate year of first occurrence)
Yes
No
Abdominal – Specify:
Appendicitis
Bleeding from Rectum
Hernia
Injury to Kidney
Injury to Spleen
Stomach Trouble – Specify:
Allergy Injection Therapy
Asthma
Blood Pressure Issues – Specify High / Low:
Blood Problems – Specify:
Anemia
Sickle Cell Anemia
Sickle Cell Trait
Transfusion
Cancer – Specify:
Chicken Pox
Cysts or Lumps – Specify:
Dermatology (Skin Disorder) – Specify:
Diabetes
Ear, Nose, Throat Problems – Specify:
Epilepsy / Seizures
Eye Problems – Specify:
Frequent Headaches
Gall Bladder Trouble or Gallstones
Head Problems – Specify:
Heart Problems – Specify:
Syncopal Episode
Chest Pain
Dizziness
Extra Heart Beat
Heart Murmur
Rheumatic Fever
Other – Specify:
2
Year
DO NOT STAPLE – KEEP RECORD IN ITS ORIGINAL ORDER – RETURN RECORD ONLY WHEN FULLY COMPLETE
Student Name:_______________________________________________________
Student ID:______________________
Yes
Hearing Loss
Hypoglycemia
Infectious Mononucleosis
Jaundice or Hepatitis
Malaria
Neurological Issues – Specify:
Head Injury – Specify:
Concussion – Specify:
Fracture – Specify:
Unconsciousness – Specify
Other – Specify:
Neck Injury – Specify:
Fracture – Specify:
Pinched Nerve – Specify:
Other – Specify:
Orthopedic Problems – Specify:
Ankle – Specify:
Arm / Elbow / Wrist / Hand/Fingers – Specify:
Back/Ribs – Specify:
Foot – Specify:
Hip / Groin – Specify:
Knee – Specify:
Lower Leg – Specify:
Shoulder – Specify:
Thigh – Specify:
Other (Stress Fracture, Etc.) – Specify:
Paralysis
Personal Trauma
Pilonidal Cyst
Sexually Transmitted Disease – Specify:
Smoke - Number of Cigarettes a Day:______
Thyroid Problems – Specify:
Tuberculosis
Urinary / Kidney Problems – Specify:
Other health problems including hospitalizations or surgical operations – Specify:
Have you ever had episodes of unexplained shortness of breath, wheezing or chest pain? – Specify:
Are you taking any medications routinely? – Specify:
Please mark “YES” if any organs are NOT intact – Specify:
Eyes
Kidneys
Lungs
Testes (Ovaries / Testicles)
Other – Specify:
If there is other medical history important to your safety or to the safety of others, please report it below:
THIS SECTION TO BE COMPLETED BY FEMALES ONLY:
Have you ever had any gynecological / obstetrics issues? – Specify:
Are you pregnant?
3
No
Year
DO NOT STAPLE – KEEP RECORD IN ITS ORIGINAL ORDER – RETURN RECORD ONLY WHEN FULLY COMPLETE
Student Name:_______________________________________________________
Student ID:______________________
Menstrual Disorder – Specify:
Part III – MENTAL HEALTH/SOCIAL HISTORY
Please note that mental health, like all of your health information, is confidential. The Health Center and the Counseling
Center are separate departments. In the future, a consent signed by the student will be obtained before sharing any
additional health information. If you wish to discuss mental health issues with a counselor or coordinate an appointment,
please call the Counseling Center at 570-372-4751.
Have you ever had or do you now have:
(Please check at right of each item and if “Yes”, indicate year of first occurrence.”)
Yes
No
Year
Depression
Anxiety
Bipolar disorder
Eating disorder
Alcohol / drug abuse or dependence
Other mental health concerns – Specify:
Please indicate if you have had the following experiences:
Yes
Attended counseling for mental health concerns
Taken a prescribed medication for mental health concerns
Been hospitalized for eating disorder / mental health concerns
Received treatment for alcohol or drug abuse
4
No
Year
DO NOT STAPLE – KEEP RECORD IN ITS ORIGINAL ORDER – RETURN RECORD ONLY WHEN FULLY COMPLETE
Student Name:_______________________________________________________
Student ID:______________________
Part IV and V - To be completed by a health care provider
Must be returned to the Health Center before July 15
or a hold will be placed on your registration, athletic participation and/or your room key will be held.
Part IV – REPORT OF PHYSICAL EXAMINATION
Physical MUST be completed within six months prior to the first day of classes, which begin August 31, 2015.
Name:
Last
Date of Entry to SU:
First
Date of Birth:
Middle
Social Security No.:
-
-
Date of Physical:
(Must be completed within six months prior to the first day of classes on August 31, 2015.)
Temperature:
Pulse:
Respiration:
Height:
Weight:
BP:
Are there abnormalities of the following systems? Please describe fully.
System
Yes
No
1. Head, Ears, Nose or Throat
2. Respiratory
3. Cardiovascular
4. Gastrointestinal
5. Hernia
6. Eyes
7. Genitourinary
8. Musculoskeletal
9. Metabolic / Endocrine
10. Neuropsychiatric
11. Skin
Is there loss or seriously impaired function of any organ? No
Recommendations for physical activity: Unlimited
Yes
Comments
Explain:
Limited
Explain:
Athlete’s clearance for full physical activity (please check one):
Granted
Granted with restrictions
Specify:
Postponed until
Rejected
Reason:
Other Recommendations:
Orthopedic screening findings or comments:
Has the patient ever been treated for an eating disorder? No
Yes
Explain:
Has the student ever been treated for any other mental health condition? No
Yes
Explain:
Is the student currently under treatment or had treatment within the past year for any medical or mental health condition? No
Explain:
5
Yes
DO NOT STAPLE – KEEP RECORD IN ITS ORIGINAL ORDER – RETURN RECORD ONLY WHEN FULLY COMPLETE
Student Name:_______________________________________________________
Student ID:______________________
Continue to next page…….
6
DO NOT STAPLE – KEEP RECORD IN ITS ORIGINAL ORDER – RETURN RECORD ONLY WHEN FULLY COMPLETE
Student Name:_______________________________________________________
Student ID:______________________
Do you have documentation of a sickle cell trait test? No _______ Yes ________ Results: Positive_______ Negative________Unknown_________
Do you have any recommendations regarding the care of this student? No
Yes
How long have you known this student?
Explain:
Do you have any general comments?
If you have any additional recommendations, please feel free to include a note or letter with this health record.
*************************************************************************************************************************************************************************************************************************************************
MUST BE SIGNED BY HEALTH CARE PROVIDER:
Health Care Provider’s Name Printed:
Health Care Provider’s Signature:
Date:
Address:
Phone: (
)
Fax:
(
)
Part V – IMMUNIZATION RECORD
To be completed and signed by a health care provider - Dates must include month(M), day(D) (if available) and year(Y).
All information, including dates, must be placed on the SU form and must be in English.
The following immunizations are for your protection as well as that of the University community.
Must be returned to the Health Center before July 15 or a hold will be placed on your registration, athletic participation and/or your room key will be held.
If you have problems obtaining your immunizations, contact your local Department of Health or high school for possible assistance.
Section I
The following immunizations are recommended but not required
A. Human Papillomavirus Vaccine (HPV2 or HPV4)
(Three doses of vaccine for female and male college students 11-26 years of age at 0, 2 and 6 month intervals.)
Immunization (indicate which preparation)
/
a. Dose #1
/
M
D
Quadrivalent (HPV4)
or
/
b. Dose #2
Y
M
/
D
Bivalent (HPV2)
M
B. Hepatitis A
1. Immunization (hepatitis A)
/
a. Dose #1
M
/
/
b. Dose #2
D
Y
M
/
D
Y
2. Immunization (combined hepatitis A and B vaccine)
/
a. Dose #1
M
/
D
/
b. Dose #2
Y
M
/
Y
C. Serogroup B Meningococcal Vaccines (MenB)
1. MenB (Bexsero®, Novartis)
/
a. Dose #1
M
/
/
b. Dose #2
D
Y
M
/
D
Y
OR (either 1 or 2)
2. MenB (Trumenba®, Pfizer)
/
a. Dose #1
M
/
D
/
b. Dose #2
Y
M
/
D
/
c. Dose #3
D
Y
7
/
c. Dose #3
Y
M
/
D
Y
/
D
Y
DO NOT STAPLE – KEEP RECORD IN ITS ORIGINAL ORDER – RETURN RECORD ONLY WHEN FULLY COMPLETE
Student Name:_______________________________________________________
Student ID:______________________
Note: Use of brand names is not meant to preclude the use of other meningococcal vaccines where appropriate.
Continue to next page…….
Section II
The following are REQUIRED immunizations.
A. MMR (Measles, Mumps, Rubella) – Two doses required at least 28 days apart for students born after 1956 and all
health sciences students.
/
1. Dose 1 given at age 12-15 months or later……………………………………………………….…………….#1
/
M
D
Y
/
2. Dose 2 given at age 4-6 years or later, and at least 28 days after first dose…………...…..……………....#2
/
M
D
Y
B. Tetanus, Diphtheria, Pertussis – Primary series with DtaP or DTP and booster with Tdap in the past 10 years meets
requirements.
1. Primary series completed?
Yes
No
/
Date of last dose in series:
M
/
D
Y
/
2. Date of most recent booster dose:
/
M
D
Type of booster: Td
Y
Tdap
Tdap booster recommended for ages 11-64 unless contraindicated.
C. Hepatitis B - Three doses of vaccine or two doses of adult vaccine or a positive hepatitis B surface antibody meets the
requirement.
1. Immunization (hepatitis B)
/
a. Dose #1
M
/
/
b. Dose #2
D
Y
M
/
2. Hepatitis B surface antibody: Date
M
/
/
D
/
c. Dose #3
D
Y
M
/
D
Y
Result: Reactive
Non-reactive
Y
D. Meningococcal – (A, C, Y, W-135) One or two doses for all college students. This is required for all students residing in a
residence hall. A second dose is required if primary dose was administered before 16th birthday.
1. Quadrivalent conjugate
/
a. Dose #1
M
/
/
b. Dose #2
D
Y
M
/
D
Y
/
2. Quadrivalent polysaccharide (acceptable alternative if conjugate not available) Date
M
/
D
Y
E. Varicella – History of chicken pox, positive varicella antibody or 2 doses of vaccine meet requirements.
1. History of Disease: Yes
2. Varicella antibody:
3. Immunization:
M
No
/
D
/
Result:
Y
Reactive
Non-reactive
a. Dose #1……………………..………………..…………………………………………….……….#1
/
/
M
D
Y
b. Dose #2 – Given at least 12 weeks after first dose ages 1-12 years and at least 4 weeks after first dose if age 13 years or
older………....…………………………………………………………………...…….…………….#2
/
/
M
D
Y
F. Polio – Primary series, doses at least 28 days apart. Three primary series schedules are acceptable.
/
1. OPV alone (oral Sabin three doses): #1
M
/
D
/
2. IPV alone (injected Salk four doses): #1
M
/
D
/
#2
Y
M
/
#2
Y
M
8
/
D
/
D
/
#3
Y
M
/
#3
Y
/
D
M
.
Y
/
D
/
#4
Y
M
/
D
Y
DO NOT STAPLE – KEEP RECORD IN ITS ORIGINAL ORDER – RETURN RECORD ONLY WHEN FULLY COMPLETE
Student Name:_______________________________________________________
Student ID:______________________
Continue to next page…….
G. PART I: Tuberculosis (TB) Screening Questionnaire (to be completed by incoming students)
Please answer the following questions:
Have you ever had close contact with persons known or suspected to have active TB disease?
Were you born in one of the countries listed below that have a high incidence of active TB disease?
(If yes, please CIRCLE the country, below)
Afghanistan
Algeria
Angola
Argentina
Armenia
Azerbaijan
Bahrain
Bangladesh
Belarus
Belize
Benin
Bhutan
Bolivia (Plurinational
State of)
Bosnia and
Herzegovina
Botswana
Brazil
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde Cambodia
Cambodia
Cameroon
Central African
Republic
Chad
China
Colombia
Comoros
Congo
Côte d'Ivoire
Democratic People's
Republic of
Korea
Democratic Republic
of the Congo
Djibouti
Dominican Republic
Ecuador
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Gabon
Gambia
Georgia
Ghana
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
India
Indonesia
Iran (Islamic
Republic of)
Iraq
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's
Democratic
Republic
Latvia
Lesotho
Liberia
Libya
Lithuania
Madagascar
Malawi
Malaysia
Maldives
Mali
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
(Federated
States of)
Mongolia
Morocco
Mozambique
Myanmar
Namibia
Nauru
□ Yes □ No
□ Yes □ No
Nepal
South Africa
Nicaragua
South Sudan
Niger
Sri Lanka
Nigeria
Sudan
Niue
Suriname
Pakistan
Swaziland
Palau
Tajikistan
Panama
Thailand
Papua New Guinea
Timor-Leste
Paraguay
Togo
Peru
Trinidad and Tobago
Philippines
Tunisia
Poland
Turkey
Portugal
Turkmenistan
Qatar
Tuvalu
Republic of Korea
Uganda
Republic of Moldova
Ukraine
Romania
United Republic of
Russian Federation
Tanzania
Rwanda
Uruguay
Saint Vincent and
Uzbekistan
the Grenadines
Vanuatu
Sao Tome and
Venezuela
Principe
(Bolivarian
Senegal
Republic of)
Serbia
Viet Nam
Seychelles
Yemen
Sierra Leone
Zambia
Singapore
Zimbabwe
Solomon Islands
Somalia
Source: Supplement – 2012 TB Incidence Rate Updated
Have you had frequent or prolonged visits* to one or more of the countries listed above with a high
prevalence of TB disease? (If yes, CHECK the countries)
□ Yes □ No
Have you been a resident and/or employee of high-risk congregate settings (e.g., correctional facilities,
long-term care facilities and homeless shelters)?
□ Yes □ No
Have you been a volunteer or health-care worker who served clients who are at increased risk for active
TB disease?
□ Yes □ No
Have you ever been a member of any of the following groups that may have an increased incidence of
latent M. tuberculosis infection or active TB disease – medically underserved, low-income or abusing
drugs or alcohol?
If the answer is YES to any of the above questions, Susquehanna University requires that you receive
TB testing as soon as possible but at least prior to the start of the subsequent semester.
□ Yes □ No
IMPORTANT NOTE: If the answer to all of the above questions is NO (PLEASE STOP HERE – SKIP PART II
AND PART III), no further testing or further action is required.
* The significance of the travel exposure should be discussed with a health care provider and evaluated.
PART II: Clinical Assessment by Health Care Provider (only complete this section if answered YES to any PART I
question)
Clinicians should review and verify the information in Part I. Persons answering YES to any of the questions in
Part I are candidates for either Mantoux tuberculin skin test (TST) or Interferon Gamma Release Assay (IGRA),
unless a previous positive test has been documented.
9
DO NOT STAPLE – KEEP RECORD IN ITS ORIGINAL ORDER – RETURN RECORD ONLY WHEN FULLY COMPLETE
Student Name:_______________________________________________________
Student ID:______________________
□ Yes □ No
□ Yes □ No
History of a positive TB skin test or IGRA blood test? (If yes, document below.)
History of BCG vaccination? (If yes, consider IGRA if possible.)
Continue to next page…….
1. TB Symptom Check - (only complete this section if answered YES to any PART I question)
Does the student have signs or symptoms of active pulmonary tuberculosis disease?
If No, proceed to
either
or
step 2
□ Yes □ No
step 3 below.
If yes, check all that apply below:
□ Cough (especially if lasting for 3 weeks or longer) with or without sputum production
□ Coughing up blood (hemoptysis)
□ Chest pain
□ Loss of appetite
□ Unexplained weight loss
□ Night sweats
□ Fever
Proceed with additional evaluation to exclude active tuberculosis disease including tuberculin skin testing, chest
x-ray and sputum evaluation as indicated.
2. Tuberculin Skin Test (TST) - (only complete this section if answered YES to any PART I question)
(TST result should be recorded as actual millimeters (mm) of induration, transverse diameter; if no induration,
write “0”. The TST interpretation should be based on mm of induration as well as risk factors.)**
/
Date Given:
M
/
D
Result:
M
mm of induration
/
Date Given:
M
/
D
Result:
/
Date Read:
Y
/
M
mm of induration
Y
**Interpretation: positive
Date Read:
Y
/
D
negative
/
D
**Interpretation: positive
Y
negative
**Interpretation guidelines:
**Interpretation guidelines
>5 mm is positive:
 Recent close contacts of an individual with infectious TB
 persons with fibrotic changes on a prior chest x-ray, consistent with past TB disease
 organ transplant recipients and other immunosuppressed persons (including receiving equivalent of >15 mg/d of prednisone for >1 month.)
 HIV-infected persons
>10 mm is positive:
 recent arrivals to the U.S. (<5 years) from high prevalence areas or who resided in one for a significant* amount of time
 injection drug users
 mycobacteriology laboratory personnel
 residents, employees, or volunteers in high-risk congregate settings
 persons with medical conditions that increase the risk of progression to TB disease including silicosis, diabetes mellitus, chronic renal failure, certain types of
cancer (leukemias and lymphomas, cancers of the head, neck or lung), gastrectomy or jejunoileal bypass and weight loss of at least 10% below ideal body
weight.
>15 mm is positive:
 persons with no known risk factors for TB who, except for certain testing programs required by law or regulation, would otherwise not be tested.
* The significance of the travel exposure should be discussed with a health care provider and evaluated.
3. Interferon Gamma Release Assay (IGRA) - (only complete this section if answered YES to any PART I question)
/
Date Obtained:
M
/
D
Result: negative
positive
/
Date Obtained:
M
Result: negative
(specify method) QFT-GIT T-Spot other
Y
/
D
indeterminate
borderline
(T-Spot only)
(specify method) QFT-GIT T-Spot other
Y
positive
indeterminate
10
borderline
(T-Spot only)
DO NOT STAPLE – KEEP RECORD IN ITS ORIGINAL ORDER – RETURN RECORD ONLY WHEN FULLY COMPLETE
Student Name:_______________________________________________________
Student ID:______________________
4. Chest x-ray: (Required if TST or IGRA is positive) - (only complete this section if answered YES to any PART I question)
/
Date of chest x-ray:
M
/
D
Result: normal
abnormal
Y
Continue to next page…….
PART III: Management of Positive TST or IGRA - (only complete this section if answered YES to any PART I question)
All students with a positive TST or IGRA with no signs of active disease on chest x-ray should receive a recommendation to be
treated for latent TB with appropriate medication. However, students in the following groups are at increased risk of progression
from LTBI to TB disease and should be prioritized to begin treatment as soon as possible.
 Infected with HIV
 Recently infected with M. tuberculosis (within the past 2 years)
 History of untreated or inadequately treated TB disease, including persons with fibrotic changes on chest radiograph
consistent with prior TB disease
 Receiving immunosuppressive therapy such as tumor necrosis factor-alpha (TNF) antagonists, systemic
corticosteroids equivalent to/greater than 15 mg of prednisone per day, or immunosuppressive drug therapy following
organ transplantation
 Diagnosed with silicosis, diabetes mellitus, chronic renal failure, leukemia or cancer of the head, neck or lung
 Have had a gastrectomy or jejunoileal bypass
 Weigh less than 90% of their ideal body weight
 Cigarette smokers and persons who abuse drugs and/or alcohol
**Populations defined locally as having an increased incidence of disease due to M. tuberculosis, including medically underserved, low-income populations
______Student agrees to receive treatment
______Student declines treatment at this time
*************************************************************************************************************************************************************************************************************************************************
MUST BE SIGNED BY HEALTH CARE PROVIDER:
Please place additional physician recommendations or comments on a separate paper. This information will be
secured with your health record.
Health Care Provider’s Name Printed:
Health Care Provider’s Signature:
Date:
Address:
Phone: (
)
Fax:
(
)
ALLERGY INJECTIONS
IMPORTANT NOTE: The SU Allergy Injection Policy must be printed and requires a signature from your allergist.
The Susquehanna University Student Health Center offers an allergy injection service for students receiving
immunotherapy ordered by their private allergist. Registered nurses are available to administer injections,
coordinate care within the student health clinic, and consult your allergist as needed.
Allergy injection students must be currently under the care of an allergist. A minimum of an annual visit to
your private allergist is required. If you are starting the first vial of any allergy injection, you must receive the
first dose from your allergist. SU nursing staff will NOT administer the first dose of any new allergy vial.
11
DO NOT STAPLE – KEEP RECORD IN ITS ORIGINAL ORDER – RETURN RECORD ONLY WHEN FULLY COMPLETE
Student Name:_______________________________________________________
Student ID:______________________
Please go to http://www.susqu.edu/health (located under the “Forms” link) to print out a copy of the Susquehanna
University Allergy Injection Policy. Once you have reviewed this policy, take the policy to your allergist for
approval. A signature is required from your allergist. The Health Center cannot administer injections without
this completed form.
Part VI – HEALTH INSURANCE INFORMATION
IMPORTANT NOTE:
Before arriving on campus, PLEASE PHONE YOUR HEALTH INSURANCE COMPANY to inform them
that your student will be attending college and may be “out of network.” Discuss the restrictions and provisions
that your primary insurance can offer your student in Selinsgrove, Pennsylvania. Please ask if Geisinger Health
Systems participates with your insurance.
With your health record, please INCLUDE A COPY OF YOUR INSURANCE CARD AND PRESCRIPTION CARD and make
sure you have a copy to carry with you to all your appointments.
PRIMARY INSURANCE INFORMATION:
Primary Insurance Company Name:
Insurance Company Address
Insurance Company Phone Number
Effective Date
Identification Number
Policy Number
Plan
Plan Code
Product Name
Group Number
Co-Pay: $
Office Visit
$
Specialty
$
ER
Policy Subscriber’s Information:
Subscriber’s Name (as appears on card)
Student Relationship to Subscriber
(ie: child, spouse, etc)
Subscriber’s Date of Birth
Employer
Subscriber’s Gender
Employer’s Phone Number
SECONDARY INSURANCE INFORMATION (If Applicable):
Secondary Insurance Company Name:
Insurance Company Address
Insurance Company Phone Number
Effective Date
Identification Number
Policy Number
Plan
Plan Code
Product Name
Group Number
Co-Pay: $
$
Office Visit
$
Specialty
ER
Policy Subscriber’s Information:
Subscriber’s Name (as appears on card)
Student Relationship to Subscriber
(ie: child, spouse, etc)
Employer
Yes
Subscriber’s Gender
Employer’s Phone Number
PRESCRIPTION COVERAGE INFORMATION:
Do you have a prescription plan? No
Subscriber’s Date of Birth
If yes, what is your co-pay?
12
DO NOT STAPLE – KEEP RECORD IN ITS ORIGINAL ORDER – RETURN RECORD ONLY WHEN FULLY COMPLETE
Student Name:_______________________________________________________
Student ID:______________________
Name of prescription plan/company:
Group No.:
A mandatory Health Center fee will be applied to your tuition, allowing no co-payment when students visit the
Susquehanna University Health Center for illness or injury. Additionally, most lab services are covered by this
“in excess” benefit package, within limits. In cases where charges exceed the plan limit, claims will be
submitted to the student’s primary insurance first. To find more information about this benefit package, please
visit the following web page: http://www.eiiastudent.org/susquehanna.
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DO NOT STAPLE – KEEP RECORD IN ITS ORIGINAL ORDER – RETURN RECORD ONLY WHEN FULLY COMPLETE
Student Name:_______________________________________________________
Student ID:______________________
Part VII – NOTICE OF PRIVACY PRACTICES
This section of Part VII to be completed by ALL STUDENTS
This section pertains to the enclosed Notice of Privacy Practices which pertains to the Health Center’s uses
and disclosures of your medical information.
IMPORTANT NOTE: The Susquehanna University Health Center is located adjacent to the Geisinger-Susquehanna
University Facility. With the student’s consent, records will be shared with this facility, as needed, for referrals.
ACKNOWLEDGEMENT OF INFORMATION PRACTICES
As part of my health care, the Health Center creates and stores information about me. This includes records concerning
my health history, symptoms, examinations, test results and plans for future care.
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I understand that this information serves as a basis for my continuing care.
I understand that this information is used as a means of communication among the Health Center personnel and
with medical personnel outside of this practice.
I understand that this information serves as a source of information for applying my diagnoses and surgical
information for billing purposes.
I understand that this information is a way for third-party insurance companies to assure that a service that was
billed for was actually performed.
I understand that this information can be used as a tool to assess the quality of care provided to patients.
I have been provided an opportunity to review the Notice of Privacy Practices for the Health Center that provides
a more complete review of information uses and disclosures.
I understand that I have the right to review this Notice of Privacy Practices before signing this consent.
I understand that the Health Center may change their information practices at any time and that a current copy
will be available for my inspection during regular business hours.
Student’s Signature:
Date:
This section of Part VII to be completed by STUDENT-ATHLETES
ONLY
PERMISSION FOR MEDICAL RECORDS RELEASE
I hereby authorize Susquehanna University’s Sport Medicine Staff and its insurance agent, to inspect or secure
copies of the Susquehanna University Health Center’s health record. I also consent for the release of medical
records of past and future confinements and/or disabilities that may affect my ability to participate in
intercollegiate athletic competition. A photo copy of this authorization shall be deemed as effective and valid as
the original.
Student-Athlete’s Signature:
Date:
ACKNOWLEDGEMENT OF RISK AND INFORMED CONSENT
I realize that participation in any sport can be a dangerous activity involving MANY RISKS OF INJURY. I
understand there are risks including and not limited to death or paralysis, brain damage, cardiac arrest, serious
injury to internal organs and to bones, joints, ligaments, muscles, tendons and other serious injury or
impairment to other aspects of my general health and well-being. I understand that the dangers and risks of
participating in sports also include the potentially high cost of medical care and impairment of my future ability
to earn a living, to engage in other business, social and recreational activities and generally to enjoy life.
Recognizing these risks, I choose to participate in the sport(s) of my choice at Susquehanna University.
Student-Athlete’s Signature:
Date:
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DO NOT STAPLE – KEEP RECORD IN ITS ORIGINAL ORDER – RETURN RECORD ONLY WHEN FULLY COMPLETE
Student Name:_______________________________________________________
Student ID:______________________
Part VIII – CONCUSSION STATEMENT
This section to be completed by STUDENT-ATHLETES
ONLY.
Susquehanna University Student-Athlete Concussion Statement
I understand that it is my responsibility to report all injuries and illnesses to my athletic trainer and/or team physician.
I have read and understand the NCAA Concussion Fact Sheet. This sheet is located at
http://www.gosusqu.com/information/sports-medicine/index.
After reading the NCAA Concussion fact sheet, I am aware of the following information:
 A concussion is a brain injury, which I am responsible for reporting to my team physician or athletic trainer.
 A concussion can affect my ability to perform everyday activities, and affect reaction time, balance, sleep, and
classroom performance.
 You cannot see a concussion, but you might notice some of the symptoms right away. Other symptoms can show
up hours or days after the injury.
 If I suspect a teammate has a concussion, I am responsible for reporting the injury to my team physician or
athletic trainer.
 I will not return to play in a game or practice if I have received a blow to the head or body that results in
concussion-related symptoms.
 Following concussion the brain needs time to heal. You are much more likely to have a repeat concussion if you
return to play before your symptoms resolve.
 In rare cases, repeat concussions can cause permanent brain damage and even death.
Student-Athlete’s Signature:
Date:
Part IX – SICKLE CELL TRAIT TESTING
This section to be completed by STUDENT-ATHLETES
ONLY.
I understand and acknowledge that the NCAA and Susquehanna University require all student-athletes to have knowledge
of their sickle cell trait status. Susquehanna University recommends that all student-athletes who are unable to confirm
their sickle cell trait status undergo testing prior to participation in any intercollegiate activity.
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Sickle cell trait is an inherited condition of the oxygen carrying protein, hemoglobin, in the red blood cells.
Sickle cell trait is a common condition affecting more than 3 million Americans.
Although sickle cell trait is most predominant in African Americans and those of Mediterranean, Middle Eastern,
Indian, Caribbean and South/Central American ancestry, persons of all races may test positive for sickle cell trait.
Sickle cell trait has been associated with a condition known as exertional rhabdomyolysis, renal failure, and death.
Complicating factors include extreme exertion, increased heat, altitude, and dehydration.
Sickle cell trait is usually benign but during intense sustained exercise, hypoxia (lack of oxygen) in the muscles
may cause sickling of red blood cells which can accumulate in the bloodstream and “logjam” blood vessels,
leading to a collapse from the rapid breakdown of muscle starved of blood.
After reviewing the above information I have elected to (please check appropriate box):
□ I know my sickle cell trait status and can provide documentation of the results.
□ I will get tested and provide documented proof of my sickle cell trait status to the sports medicine staff.
□ I do not wish to undergo sickle cell trait testing and I voluntarily agree to release, discharge, indemnify
and hold harmless Susquehanna University from any and all costs, liabilities, expenses, claim demands,
or causes of actions on account of any loss or personal injury that might result from my non-compliance
with the NCAA and Susquehanna University recommendation of knowing my sickle cell trait status.
Student-Athlete’s Signature:
Date:
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