Pre-Entrance Health Record Forms must be completed by ALL undergraduates.

Pre-Entrance Health Record
Forms must be completed by ALL undergraduates.
Please return completed health form with all additional requirements by:
July 1 for Fall Enrollment • December 10 for Spring Enrollment
PLEASE PRINT CLEARLY
Name:
Sex:
LAST
FIRST
Date of Birth:
/
MM
/
DD
MIDDLE
Email that you check regularly:
YYYY
Address:
City:
Home Phone: (
)
Year Entering WJU:
Please check:
Student Cell Phone: (
(Please check):
)
____________
___State/Country:
Zip:
Please check one:
❍ Commuter ❍ Campus Resident
❍ Entering Fall Semester ❍ Entering Spring Semester
❍ Entering as a Freshman ❍ Re-admitted to WJU -- your last semester attended was: ___________________
❍ Transferring in
Your intended major (s): ________________________________________________________ Your intended athletic sport, if any: _____________________________________
Emergency Contact Person:
)
❍ None
Relationship:
Address:
Home Phone: (
❍M ❍ F
Alternative Phone: (
City:
State/Country:
Zip:___________________
)
Emergency Contact Email:
_________________________
Family Physician / Health Care Provider:
Phone: (
Address:
)
State/Country:
Zip:
MANDATORY AUTHORIZATION TO RENDER HEALTH SERVICES (IF YOU ARE 18 YEARS OF AGE OR OLDER).
I hereby authorize Wheeling Jesuit University’s Student Health Center to render services deemed necessary for my health and well-being. I grant
permission for my transfer to an accredited hospital or other care facility if deemed necessary by the Dean of Student Development or his/her designee.
I agree to be responsible for any expense in connection with the aforesaid, if my insurance does not provide payment of the same. I grant permission for
the hospital or other care facility to provide information concerning my treatment by their facility to Wheeling Jesuit University’s Health Center for
continuity of care.
Student Signature:
Date:
MANDATORY AUTHORIZATION FROM PARENT/GUARDIAN IF YOU ARE A MINOR (UNDER THE AGE OF 18).
I hereby authorize Wheeling Jesuit University’s Student Health Center to render confidential health services deemed necessary for my/our minor child’s
health and well-being. These services are inclusive of nursing services and counseling support services.
In addition, I grant permission for my child’s transfer to an accredited hospital or other care facility if deemed necessary by the Dean of Student
Development or his/her designee. I agree to be responsible for any expense in connection with the aforesaid, if my child’s insurance does not provide
payment of the same. I grant permission for the hospital or other care facility to provide information concerning my child’s treatment by their facility to the
Wheeling Jesuit University Health Center for continuity of care.
Parent/Guardian Signature:
Date:
Please return forms and all additional documents requested on page 3 by:
July 1 for Fall Enrollment • December 10 for Spring Enrollment
In case your records are not received, please
please make a copy of all of your documents before mailing them to the Student Health Center
Cen ter.
ter.
Mail to:
Pg 1 of 3
The Student Health Center
Wheeling Jesuit University
316 Washington Ave.
Wheeling, WV 26003
For questions or concerns, please call: 304-243-2275
or email: [email protected] (please put your name in the subject line)
REV / Feb 2016
FOR OFFICE USE ONLY
Personal Health History
Reviewed by: WJU RN:
Date:
Forms must be completed by ALL undergraduate students.
This information will be used only as an aid in the consideration of your health needs and will remain confidential among the appropriate healthcare professionals. PLEASE
USE ADDITIONAL SHEETS OF PAPER IF NECESSARY.
Are you presently under any medical treatment?
If yes, explain: _____________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
________
Are you presently taking any medications (prescription, nonprescription, inhaler)?
If yes, explain: _____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
Are you now receiving or have you ever received professional help for emotional or psychological problems?
If yes, when: _____________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
_______________
Do you have a physical impairment such as paralysis, loss of vision, loss of hearing, etc.?
If yes, explain: _____________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
________
Do you have any sensitivity to food, medicine, or environmental contact?
If yes, explain: _____________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
________
Have you ever had a head injury or concussion?
If yes, explain and give dates: _____________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Has a physician
cian ever denied or restricted your participation in sports for any health problems?
If yes, explain: _____________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
________
Have you ever had, or do you currently have (CHECK ALL THAT APPLY):
❍ Anemia
❍ Anxiety
❍ Asthma/Exercise Induced Asthma
❍ Bladder/Kidney Problems
❍ Bleeding Disorders
❍ Blood Clots (Leg/Lung)
❍ Cancer (Type:___________________________________________________________________)
❍ Cardiac Disease (Type: _________________________________________________________)
❍ Chicken Pox
❍ Depression
❍ Dermatological Issues (Type: _______________________________________________________________)
❍ Diabetes
❍ Fractures
Where?_______________________________________________________________
❍ Gallbladder Disease
(Hyperglycemia/Hypoglycemia)
(Broken Bones)
❍ Yes
❍ No
❍ Yes
❍ No
❍ Yes
❍ No
❍ Yes
❍ No
❍ Yes
❍ No
❍ Yes
❍ No
❍ Yes
❍ No
❍ Gastrointestinal Issues
❍ Gynecological Issues
❍ Mononucleosis
❍ Seizures
❍ STDs
❍ Suicidal/Homicidal Ideation
❍ Thyroid Disease
(Heartburn/GERD/Irritable Bowel)
(Hyperthyroidism/Hypothyroidism)
If you checked any of the above, please provide further information:
Dates of significant injuries or operations or medical admissions to hospitals:
Personal Habits (please indicate use of any of the following):
Tobacco Use:
Never
No
Yes Quit Date:
❍
❍
❍
Current Smoker: Packs / day:
Alcohol Use: Do you drink alcohol?
# of years:
❍ No ❍ Yes
❍ NONE
How many years did you smoke?
Other tobacco:
# of drinks/week:
❍ Pipe ❍ Cigar ❍ Snuff ❍ Chew
❍ Beer ❍ Wine ❍ Liquor
If you wish to receive care for any health problem or concern at the WJU Student Health Center, please bring copies of any appropriate medical records with you to campus
and call (304) 243-2275 for an appointment.
I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.
Student Name (please print):
Signature:
Date:
Parent/guardian (if student is under the age of 18): (print)
Signature:
Date:
(The Registered Nurse or Counselor may request a consult with the student for basic information and support purposes.)
Please return forms and all additional documents requested on page 3 by:
July 1 for Fall Enrollment • December 10 for Spring Enrollment
Mail to:
The Student Health Center
Wheeling Jesuit University
316 Washington Ave.
Wheeling, WV 26003
For questions or concerns, please call: 304-243-2275
304
or email: [email protected] (please put your name in the subject line)
SEND ALL DOCUMENTS TOGETHER
Pg 2 of 3
REV / Feb 2016
Additional Requirements
Name: (please print clearly) __________________________________________________________________________________________________________________________
Date of birth: _________________________________
START PREPARING YOUR RECORDS EARLY TO AVOID A DELAY IN PROCESSING! Below is a list of additional requirements. Please attach official
medical documentation of each requirement to your health forms and submit them together.
You must make every effort to meet the required submission deadline to give the Student Health Center time to review your records for accuracy. The
Student Health Center will then have time to alert you of any deficient records giving you time to bring all requirements up-to-date before you move onto
campus or attend classes.
1)
Proof of health insurance coverage. This can be a photocopy of your card (front and back) or a letter of coverage from your insurance provider.
You will be expected to maintain health insurance coverage at all times while enrolled as a student at WJU. Your medical insurance information will
be kept confidential and on file for scheduling medical referrals to outside physicians, outpatient treatment, and for emergencies.
2)
TST (tuberculin skin test): This is not an immunization, so you may never have had one before. This skin test is a method of determining whether
a person is infected with Mycobacterium tuberculosis. You will expect to return to your doctor within 48-72 hours so that your arm can be checked
for the result. If your result is positive, please provide your doctor’s plan of treatment. Failure to have the result documented will mean that you
will have to repeat the test. Please note: if your doctor is unavailable to provide this test, you can also get it through your county health
department or a walk-in urgent care type clinic. An assessment questionnaire will not be accepted.
3)
Immunizations:
Immunizations : You can get documentation from your doctor OR check with your previous school to see if they have a record on file. If you need to
get one or more of these vaccines, please visit your family physician, your county health department, or an urgent care walk-in type clinic.
• MMR (measles, mumps, rubella) , 2 doses OR a blood screening for each disease that shows that you have immunity.
• Tdap (tetanus, diphtheria, acellular pertussis), 1 dose - Important note: if your last Tdap vaccine was given more than ten years ago then you are
required to get a Tdap booster. The booster must contain all three components.
Additional immunizations that are strongly recommended, but not mandatory if you sign and date the waiver
waivers. Health science majors may be
required to show proof of these vaccines for their program.
• Hepatitis B (3 dose series) Please visit the Center of Disease Control website (www.cdc.gov) for more information
I have read the vaccine statement from the CDC and understand the risks of declining the hepatitis B vaccine. I hereby release Wheeling Jesuit
University, its officers, trustees, employees and agencies in which I practice during my role as a student from any and all liability that may arise directly
or indirectly as a result of my choice not to receive the hepatitis B vaccine.
Sign: ____________________________________________________________________________________________________________________________ Date: ________________________________________________
• Meningococcal vaccine - Please visit the Center of Disease Control website (www.cdc.gov) for more information
I have read the vaccine statement from the CDC and understand the risks of declining the meningococcal vaccine. I hereby release Wheeling Jesuit
University, its officers, trustees, employees and agencies in which I practice during my role as a student from any and all liability that may arise directly
or indirectly as a result of my choice not to receive the meningococcal vaccine.
Sign: ____________________________________________________________________________________________________________________________ Date: ________________________________________________
Attention WJU athlete:
You must contact your coach for additional health requirements for the athletic program. Important: do not send your PrePre-Entrance Health
H ealth
R ecords to the Athletic department.
department If records are sent to the wrong department, you may be asked to resend them. A delay in receiving your health
enrollment records will cause a delay in your clearance process to move into your residence hall.
Please check that you are enclosing each of these documents.
__page one of the health form
__ tuberculin skin test, with result
__page two of the health form
__MMR immunization (2 doses)
__proof of health insurance
__Tdap immunization (1 current dose)
__ Hepatitis B (3 doses) OR signed waiver
__ Meningococcal OR signed waiver
SEND ALL DOCUMENTS TOGETHER
I have made a copy of all documents for my personal file before submitting to the Student Health Center:______________________________________________________ Date:___________
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