Orientation
Entrance Health Report
2009
Please review your Health Forms using the checklist below to be sure you and your Health Care Provider complete all required information. Students will not be allowed to move into the residence halls or register for classes until all of the required health forms are on file.
Deadline: Friday, July 10, 2009
TO BE COMPLETED BY THE INCOMING STUDENT These pages are marked in blue throughout this report.
Demographic Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Family History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Student’s Medical History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Insurance Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Please be aware that you will be required to submit Insurance Information to Student Financial Services and to Athletics, if you are participating in athletics. Permission for Medical & Emergency Treatment . . . . . . . . . . . . . . . . . . . . . . . . . 5 This section must be completed by the parent or legal guardian if the incoming student is under 18. Meningococcal Vaccination Waiver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-8 This form must be filled out and signed if you have declined vaccination. Tuberculosis Risk Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Make a copy of completed Health Forms to save for your records
TO BE COMPLETED AND SIGNED BY THE HEALTH CARE PROVIDER These pages are marked in grey throughout this report.
Medical Evaluation for Latent Tuberculosis Infection . . . . . . . . . . . . . . . . . . . . . . 10
Physical Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Immunization Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Please return all completed forms in the envelope provided to: Student Health Services Emmanuel College 400 The Fenway Boston, MA 02115 617-264-7678 For inquiries May through August, call 617-735-9920
Student Information
When finished, please return to: Student Health Services Emmanuel College 400 The Fenway Boston, MA 02115
Demographic Information It is important that you provide a complete address. Entrance Date Last Name
First Name
Middle Initial
Date of Birth
Expected Graduation Year
Home Address (Apt. No., Street, Post Office Box, etc.)
City
State
Zip Code
Home Phone Number
Cell Phone Number
Father’s Name
Occupation
Home Address (Apt. No., Street, Post Office Box, etc.)
City
State
Zip Code
Home Phone Number
Work Phone Number
Mother’s Name
Occupation
Home Address (Apt. No., Street, Post Office Box, etc.)
City
State
Zip Code
Home Phone Number
Work Phone Number
Emergency Contact
Relation to Student
Home Phone Number
Work Phone Number
Home Address (if different than above)
City
State
Zip Code
Male
Female
Deadline: Friday, July 10, 2009
Family History Father
Age
General Health
Past/Present Illness
If deceased, cause of death
Age
General Health
Past/Present Illness
If deceased, cause of death
Mother
Siblings
M/F
Age
General Health
Past/Present Illness
If deceased, cause of death
M/F
Age
General Health
Past/Present Illness
If deceased, cause of death
M/F
Age
General Health
Past/Present Illness
If deceased, cause of death
Please indicate below if any of your family has had the following: Alcoholism Heart Disease (before age 55) Asthma High Cholesterol Cancer Hypertension Drug Abuse Psychiatric Disorder Epilepsy Stroke
Tuberculosis Other:______________________ ____________________________
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Student’s Medical History Please list all medications and dosage you are currently taking:
Please list and describe any medication allergies you have: When finished, please return to: Student Health Services Emmanuel College 400 The Fenway Boston, MA 02115
Deadline: Friday, July 10, 2009
Please list current medical problems:
Please indicate below if you have had the following: Allergies Head injury Alcohol/drug problems Headaches Anorexia/Bulimia Heart Disease Asthma Hepatitis Blood Disorders High Cholesterol Blood Transfusions Hypertension Cancer Irritable Bowel Syndrome Chicken Pox Kidney Disease Diabetes Liver Disease Depression Malaria Ear Infections Menstrual Cycle: Eye Problems/Trauma # periods in last year:________ Fainting/spells Mononucleosis German Measles Numbness/tingling
Pneumonia Panic Attacks Psychiatric Disorders Sickle Cell Disease Skin Disorder: acne, eczema, tinea Seizures Sexually transmitted diseases Thyroid Disorder Tuberculosis Ulcers Other (please explain):________ ____________________________ ____________________________
Regarding sports related illness or injury, please complete the following: 1. Have you ever had trouble with sports or physical activity (passed out, chest pain, shortness of breath, etc.)?
Yes
No If yes, please describe
2. Have any restrictions ever been placed on you as to the amount and nature of your physical activity?
Yes
No If yes, please describe
3. Do you use any special protective/assistive equipment (knee brace, hearing aid, orthotics, retainers, etc.)?
Yes
No If yes, please describe
4. Have you ever had any of the following sports injuries or hospitalizations? Yes No Date Neck injury (stingers, burners, disc injury) ________________ Shoulder/Elbow (separation, dislocation, fracture) ________________ Wrist/Hand (fracture) ________________ Hip/Thigh (sacroiliac, femur) ________________ Upper/Lower Back (disc herniation, spondilolysis) ________________ Knee (patella pain, ligament sprain, meniscus) ________________ Lower Leg (fracture, stress fracture) ________________ Ankle (sprain, dislocation, fracture) ________________ Foot (sprain, fracture) ________________ Surgery ________________ If yes to surgery, please describe
I hereby certify that the above information is complete and accurate.
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Student Signature
Date
Insurance Information This information must be provided.
Student Last Name
First Name
Middle Initial
I plan to be covered by school insurance. I will be covered by:
When finished, please return to: Student Health Services Emmanuel College 400 The Fenway Boston, MA 02115
Name of Insurance Company Policy Number Name of Policy Holder Social Security Number of Policy Holder
Deadline: Friday, July 10, 2009
Does your insurance company require prior approval for specialty referrals? Yes
No If yes, contact names and telephone number
Permission for Medical & Emergency Treatment This information must be completed and signed by parent or legal guardian if student is under 18.
Student Last Name
First Name
Middle Initial
Medical treatment: This is to certify that permission is granted to Emmanuel College Student Health Services to provide medical treatment for illness, injury or required immunizations for the above-named student.
Signature of parent or legal guardian
Emergency treatment: Permission is granted for emergency treatment (including surgery & anesthesia) for above named student, when parent or guardian is unable to be contacted.
Signature of parent or legal guardian
In all cases, reasonable effort will be made to contact parent or guardian prior to treatment.
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Information about Meningococcal Disease & Vaccination and Waiver for Students at Residential Schools & Colleges
Legislation has been enacted in Massachusetts requiring all new students at residential schools (e.g., boarding schools) with grades 9-12 and postsecondary institutions (e.g., colleges) that provide or license housing to: 1. receive meningococcal vaccine prior to the beginning of classes; or 2. fall within one of the exemptions in the law, which are discussed below. The law provides an exemption for students signing a waiver that reviews the dangers of meningococcal disease and indicates that the vaccination has been declined. To qualify for this exemption, you are required to review the information below and sign the waiver at the end of this document. Please note, if a student is under 18 years of age, a parent or legal guardian must be given a copy of this document and must sign the waiver.
are at an increased risk for meningococcal disease as compared to individuals of the same age not attending college. The setting, combined with risk behaviors (such as alcohol consumption, exposure to cigarette smoke, sharing food or beverages, and activities involving the exchange of saliva), may be what puts college students at a greater risk for infection. There is insufficient information about whether new students in other congregate living situations (e.g., residential schools) may also be at increased risk for meningococcal disease. But, the similarity in their environments and some behaviors may increase their risk.
When finished, please return to: Student Health Services Emmanuel College 400 The Fenway Boston, MA 02115
Deadline: Friday, July 10, 2009
The risk of meningococcal disease for other college students, in particular older students and students who do not live in congregate housing, is not increased. However, meningococcal vaccine is a safe and efficacious way to reduce their risk of contracting this disease.
What is meningococcal disease?
Is there a vaccine against meningococcal disease?
Meningococcal disease is caused by infection with bacteria called Neisseria meningitidis. These bacteria can infect the tissue that surrounds the brain and spinal cord called the “meninges” and cause meningitis, or they can infect the blood or other body organs. In the United States, about 2,600 people each year get meningococcal disease and 10-15% die despite receiving antibiotic treatment. Of those who survive, about 10% may lose limbs, become deaf, have seizures or strokes, or have other problems with their nervous system.
Yes, there are currently two vaccines available that protect against four of the most common of the 13 serogroups (subgroups) of N. meningitidis that cause serious disease. Meningococcal polysaccharide vaccine is approved for use for those two years of age and older. In January 2005, a new type of meningococcal vaccine was licensed, called meningococcal conjugate vaccine, and is currently only approved for use for those 11-55 years of age. Both types of meningococcal vaccines are acceptable for college students and residential school students 11 years of age and older. For those younger than 11 years of age, meningococcal polysaccharide vaccine is the only licensed vaccine.
How is meningococcal disease spread? These bacteria are passed from person-to-person through saliva (spit). You must be in close contact with an infected person’s saliva in order for the bacteria to spread. Close contact includes activities such as kissing, sneezing, coughing, sharing water bottles, sharing eating/drinking utensils or sharing cigarettes with someone who is infected.
Who has the greatest risk of getting meningococcal disease? People who travel to certain parts of the world where the disease is very common are at risk, as are military recruits who live in close quarters. Children and adults with damaged or removed spleens or an inherited disorder called “terminal complement component deficiency” are at higher risk.
Are some students in college and secondary schools at risk for meningococcal disease? College freshmen living in residence halls or dormitories
Both of the vaccines provide protection against four serogroups of the bacteria, called groups A, C, Y and W-135. These four serogroups account for approximately two-thirds of the cases that occur in the U.S. each year. Most of the remaining one-third of the cases are caused by serogroup B, which is not contained in the vaccine. Protection from immunization with the meningococcal polysaccharide vaccine is not lifelong; it lasts about 3-5 years in healthy adults (some people may be protected longer). The meningococcal conjugate vaccine is expected to help decrease disease transmission and provide more long-term protection.
Is the meningococcal vaccine safe? A vaccine, like any medicine, is capable of causing serious problems such as severe allergic reactions. The risks associated with receiving the vaccine are much less significant than the risks that would arise in a case of meningococcal disease. Getting meningococcal vaccine is much safer than getting the disease. Some people who get meningococcal
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vaccine have mild side effects, such as redness or pain where the shot was given. These symptoms usually last for 1-2 days. A small percentage of people who receive the vaccine develop a fever. The vaccine can be given to pregnant women.
When finished, please return to: Student Health Services Emmanuel College 400 The Fenway Boston, MA 02115
Deadline: Friday, July 10, 2009
Is it mandatory for students to receive meningococcal vaccine prior to entering secondary schools or colleges that provide or license housing? Massachusetts law (MGL Ch. 76, s.15D) requires new students at residential schools (e.g., boarding schools) with grades 9-12 and new full- and part-time, undergraduate and graduate students in degree-granting programs at postsecondary institutions (e.g., colleges) that provide or license housing to receive meningococcal vaccine. At affected institutions, the new requirements apply to all new students, regardless of grade (including grades pre-K through 8), year of study, and whether or not they reside in school- or campus-related housing. Since August 2005, all new students at these institutions have had to provide documentation of having received meningococcal vaccine (within the last five years) at least two weeks prior to the beginning of classes, unless they qualified for one of the exemptions allowed by the law. Students may begin classes without a certificate of immunization against meningococcal disease if: 1) the student has a letter from a physician stating that there is a medical reason why he/she can’t receive the vaccine; 2) the student (or the student’s parent or legal guardian,
if the student is a minor) presents a statement in writing that such vaccination is against his/her sincere religious belief; or 3) the student (or the student’s parent or legal guardian, if the student is a minor) signs the waiver below stating that the student has received information about the dangers of meningococcal disease, reviewed the information provided and elected to decline the vaccine. Consideration is being given to amending the law regarding the students to be covered by the requirement. When and if the law is amended, regulations regarding meningococcal vaccination may change.
Where can a student get vaccinated? Students and their parents should contact their healthcare provider and make an appointment to discuss meningococcal disease, the benefits and risks of vaccination, and the availability of this vaccine. Schools and college health services are not required to provide you with this vaccine.
Where can I get more information? • Your healthcare provider • The Massachusetts Department of Public Health, Division of Epidemiology and Immunization at 617-983-6800 or www.mass.gov/dph • Your local health department (listed in the phone book under government)
Waiver for Meningococcal Vaccination Requirement I have received and reviewed the information provided on the risks of meningococcal disease and the risks and benefits of meningococcal vaccine. I understand that Massachusetts’ law requires students enrolled at secondary schools, colleges and universities that provide or license housing to receive meningococcal vaccinations, unless the students provide a signed waiver of the vaccination or otherwise qualify for one of the exemptions specified in the law. Please check the appropriate box below: After reviewing the materials above on the dangers of meningococcal disease, I choose to waive receipt of meningococcal vaccine. Due to the shortage of meningococcal vaccine, I was unable to be vaccinated.
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Last Name
First Name
Date of Birth
Student ID or SSN
Signature of student or parent/legal guardian, if student is under 18
Date
Middle Initial
Provided by: Massachusetts Department of Public Health / Division of Epidemiology and Immunization / 617-983-6800 MDPH Meningococcal Information and Waiver Form
June 2006
Tuberculosis Risk Questionnaire for College and University Students
Last Name
First Name
Middle Initial
1. To the best of your knowledge have you ever had close contact with anyone who was sick with tuberculosis (TB)?
Yes
No
Deadline: Friday, July 10, 2009
2. Were you born in one of the countries listed below?
Yes
When finished, please return to: Student Health Services Emmanuel College 400 The Fenway Boston, MA 02115
No
3. Have you traveled or lived for more than one month in one or more of the countries listed below?
Yes
No
Countries with High Rates of Tuberculosis (TB)* Afghanistan Angola Armenia Azerbaijan Bahamas Bahrain Bangladesh Belarus Benin Bhutan Bolivia Bosnia & Herzegovina Botswana Brazil Brunei Darussalam Burkina Faso Burundi Cambodia Cameroon Cape Verde Central African Rep. Chad China China, Hong Kong SAR China, Macao SAR Colombia Comoros Congo Congo, DR Cote d’Ivoire Croatia
Djibouti Dominican Rep. Ecuador El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Gabon Gambia Georgia Ghana Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras India Indonesia Iran Iraq Kazakhstan Kenya Kiribati Korea, DPR Korea, Rep. Kyrgyzstan Lao PDR Latvia
Lesotho Liberia Lithuania Macedonia, TFYR Madagascar Malawi Malaysia Maldives Mali Marshall Islands Mauritania Mauritius Micronesia Moldova, Rep. Mongolia Morocco Mozambique Myanmar Namibia Nepal New Caledonia Nicaragua Niger Nigeria Niue Northern Mariana Islands Pakistan Palau Panama Papua New Guinea Paraguay
Peru Philippines Portugal Romania Russian Federation Rwanda Sao Tome & Principe Senegal Sierra Leone Solomon Islands Somalia South Africa Sri Lanka Sudan Suriname Swaziland Syrian Arab Rep. Tajikistan Tanzania, UR Thailand Togo Tokelau Turkmenistan Uganda Ukraine Uzbekistan Vanuatu Vietnam Yemen Zambia Zimbabwe
* World Health Organization. Global tuberculosis control. WHO report 2002. If the answer to any of the above questions is YES, the Massachusetts Department of Public Health strongly recommends that you have a tuberculin skin test to check for latent tuberculosis infection. If the answer to all of the above questions is NO, you do not need a skin test so have your physician indicate low risk below and sign this form. If you have had a positive tuberculin skin test in the past, you do not need another one.
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Medical Evaluation of College and University Students for Latent Tuberculosis Infection
When finished, please return to: Student Health Services Emmanuel College 400 The Fenway Boston, MA 02115
Deadline: Friday, July 10, 2009
Student’s Last Name
First Name
Middle Initial
Risk Assessment Score Please check one of the following: Low (if low, no test needed) — Health Care Provider, please sign below. High (skin test performed) Very High (skin test performed)
Tuberculin Skin Test mm of induration Date Performed
Result (48-72 hours)
(If no induration, mark “0”) Note: Use 5 TU Mantoux test (Intermediate PPD) only; result of multiple puncture tests, such as Tine or Mono-vacc, not accepted.
Interpretation of Tuberculin Skin Test Risk Factor Assessment
Positive Result Parameters
Very High—Close contact with a case of tuberculosis
5 mm or more
High—Born in a country that has a high rate of tuberculosis High—Traveled or lived for a month or more in a country that has a high rate of tuberculosis
10 mm or more
Low—None (test not recommended)
15 mm or more
Risk-based Interpretation Negative Positive
If the Tuberculin Skin Test is positive: Chest X-ray Date Performed
Normal Abnormal If abnormal, please describe
Clinical Evaluation Date Performed
Normal Abnormal
If abnormal, please describe
Treatment No Yes If yes, please describe (drug, dose, frequency and dates)
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Health Care Provider’s Signature
Date
Physical Exam Date of Physical Exam*: ______________________________ * Please note: physical exam must have been completed within the last 12 months.
Student’s Last Name
First Name
When finished, please return to: Student Health Services Emmanuel College 400 The Fenway Boston, MA 02115
Middle Initial
General Appearance
Vital Signs: Blood Pressure
Pulse
Weight
Height
Deadline: Friday, July 10, 2009
Please check each item: Normal Abnormal If Abnormal, please describe: Eyes __________________________________________________ Ears __________________________________________________ Nose/Sinus __________________________________________________ Throat/Tonsils __________________________________________________ Teeth/Gums __________________________________________________ Chest __________________________________________________ Lungs __________________________________________________ Heart __________________________________________________ Heart murmur with valsalva __________________________________________________ Thyroid __________________________________________________ Breasts __________________________________________________ Abdomen __________________________________________________ Liver __________________________________________________ Lymph __________________________________________________ Spleen __________________________________________________ Rectum __________________________________________________ Pelvis/Genitourinary __________________________________________________ Neurologic Exam __________________________________________________ Rheumatologic __________________________________________________ Orthopedic Exam __________________________________________________ Skin __________________________________________________ *Please complete attached immunization information and TB Risk assessment. Recommendations:
Applicant may participate in sports: may participate without restrictions with the following restrictions:___________________________________________________________________________ should not participate in sports
Health Care Provider’s Signature
Date
MD
NP
PA
Health Care Provider’s Name (please print) Address
City
Phone Number
Fax Number
State
Zip Code
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Immunization Requirements
When finished, please return to: Student Health Services Emmanuel College 400 The Fenway Boston, MA 02115
Deadline: Friday, July 10, 2009
Failure to provide a record of your immunization will result in registration restrictions and withholding of grades. Massachusetts State Law requires that all students attending college in the Commonwealth be immunized against Measles, Mumps, Rubella (MMR), Tetanus and Diphtheria (Td). Meningitis is required as of January 2003. Three doses of Hepatitis B are MANDATORY for First-Year Students. Measles, Mumps, Rubella (MMR): All students must have a signed statement from a health official who administered vaccines for: 2 doses of measles, mumps, rubella (MMR) OR copies of laboratory evidence of immunity to all of the above Tetanus and Diphtheria: All students are required to have a Tetanus Booster within the last ten years (Td or Tdap). If you do not have access to these records, you must be re-immunized.
Student’s Last Name
First Name
Middle Initial
Date of Birth
Social Security Number
Proof of the following immunizations must be on file in Student Health Services:
Measles, Mumps, Rubella (MMR)
Hepatitis B
First Dose
Second Dose
Date
Date
First Dose
Second Dose Third Dose
Date
Date
OR
Laboratory evidence of immunity to measles, mumps and rubella attached
OR
Laboratory evidence of immunity attached
OR
Waiver signed and attached (see pages 7 & 8)
OR
Tetanus, Diptheria & Acellular Pertussis (Tdap)
Date
Meningitis Date
Tetanus Booster (within the last 10 years)
Tetanus & Diptheria (Td)
Date
Tuberculosis Risk Assessment
Date
Low Risk High Risk If high risk, testing date and results
Varicella
First Dose
Second Dose
Date
Date
OR
Laboratory evidence of immunity to Varicella History of Varicella Disease Date
Health Care Provider’s Signature
Date
MD
NP
PA
Health Care Provider’s Name (please print)
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Address
City
Phone Number
Fax Number
State
Zip Code