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CONFIDENTIAL Page 1 of 7 CONFIDENTIAL HEALTH REPORT (State University of New York at Plattsburgh)

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CONFIDENTIAL HEALTH REPORT
Page 1 of 7
CENTER FOR STUDENT HEALTH AND
PSYCHOLOGICAL SERVICES
INTERNATIONAL STUDENT
HEALTH REPORT
CENTER FOR STUDENT HEALTH AND
PSYCHOLOGICAL SERVICES
CONFIDENTIAL
CONFIDENTIAL HEALTH REPORT
Page 2 of 7
CENTER FOR STUDENT HEALTH AND
PSYCHOLOGICAL SERVICES
Relationship to you
(e.g. father, mother)
E-mail
Home Address
of Emergency
Contact
Given NameFamily Name
Date of Birth (mm/dd/yyyy)
ID Number (i.e. your 700
number)
Given Name
Family Name
Please print or type all information.
Number
City Code
Country Code
Other Phone Number of
Emergency Contact
NumberCity CodeCountry Code
Home Phone Number
of Emergency Contact
Semester of enrollment
Permanent Address (required)
Type exactly as it should appear in English on an
envelope.
Email address (required)
Gender (required)
STUDENT INFORMATION (TO BE COMPLETED BY STUDENT)
EMERGENCY PERSON CONTACT INFORMATION (TO BE COMPLETED BY STUDENT)
CONFIDENTIAL HEALTH REPORT
Page 3 of 7
CENTER FOR STUDENT HEALTH AND
PSYCHOLOGICAL SERVICES
10. Voluntary Self-Identification: Please
complete this question if you have a physical or
learning disability and would like to receive
information about specific services that may be
available to support your success in college.
This question is optional, will remain
confidential, and will not in anway affect your
academic or personal status at this college.
Describe the nature of your disability.
9. Please explain everything
you checked above
Kidney disease
Diabetes
High blood pressure
Heart disease
Intestinal disorders
Depression
Chronic lung disease
Cancer
Alcoholism
7. Please list any medications, vitamins,
supplements, or birth control that you take on a
regular basis (include the name, dose, and
frequency of the item.
6. Do you have allergies to food, medications, or
latex? If yes, please describe.
5. Do you have any restrictions on your
physical or learning activity? If yes, please
describe.
4. Have you ever had any sports-related
injuries? If yes, please describe.
3. Have you ever been hospitalized or had any
surgery? If yes, please describe the problem,
when it occurred, and where.
2. Please explain everything you checked
above
Thyroid disease
Sexually transmitted infections
Rheumatic fever
Migraine headaches
Loss of consciousness
Kidney disease
Injury to legs, feet, arms, or hands
Inflammatory bowel syndrome
Infectious mononucleosis
High blood pressure
Hernia
Hypoglycemia
Hepatitis
Heart disease/murmur
Head injury/concussion
Gynecological disorders
Depression/anxiety
Disorders of eye, ear, nose, or throat
Diabetes
Cystitis or urinary infections
Convulsions/seizures
Chicken pox
Cancer
Bulimia
Blood disorders
Back problems
Anorexia
Allergies/hay fever
Alcohol/substance abuse
Abnormal PAP smear
Date of Birth (mm/dd/yyyy)
Family Name
1. Have you ever been or are you currently treated for any of the following (check appropriate boxes)?
8. Does your family have a history of any of the following (check appropriate box)?
MEDICAL HISTORY (TO BE COMPLETED BY STUDENT)
CONFIDENTIAL HEALTH REPORT
Page 4 of 7
CENTER FOR STUDENT HEALTH AND
PSYCHOLOGICAL SERVICES
Record the Date of Each Dose
The State of New York and SUNY Plattsburgh require that all students be immunized against measles (rubeola), mumps,
and rubella. Polio and tetanus/diptheria immunizations are recommended, but not required. We also recommend students
to be screened for tuberculosis with a PPD (mantoux). Please provide the student's immunization record by answering the
questions below. If you have any questions or need help please contact Linda Dragon at 518-564-2187 (email: linda.
dragon@plattsburgh.edu).
1. MMR (required)
Two doses required. Skip to #5 if complete.
2. Rubeola (required in absence of MMR) Two doses
required. Proof of the disease or immune titer is
acceptable in lieu of the vaccine. Please record date of
the disease or attach a copy of the immune titer report.
3. Mumps (required in absence of MMR) One dose
required. Proof of the disease or immune titer is
acceptable in lieu of the vaccine. Please record date of
the disease or attach a copy of the immune titer report.
4. Rubella (required in absence of MMR) One dose required.
Proof of immune titer is acceptable in lieu of the vaccine.
Please attach a copy of the immune titer report.
5. Polio (recommended but not required) Three doses
required for all students 18 and under. For those 19 and
over, record the date of previous doses but no additional
doses should be given.
6. Tetanus/Diptheria (recommended but not required) At
least three doses required and the most recent must be
within 10 years of the student's enrollment date.
7. PPD (recommended within six months of the physical)
An x-ray is required if the PPD is positive.
8. Varicella (recommended but not required) Two doses.
Proof of the disease or immune titer is accept- able in
lieu of the vaccine. Please record date of thedisease or
attach a copy of the immune titer report.
9. Hepatitis B Vaccine (recommended but not required)
Three doses.
10. Pneumovax (not required)
One dose.
11. Meningococcal (recommended but not required)
One dose.
Date PPD
Administered
Date PPD
Interpreted
Result
X-ray Date
X- ray Result
Student ID #
Student Name
Provider Name
Provider Signature
Provider
Address
Provider Phone
1st dose 2nd dose
3rd dose
4th dose
5th dose
Positive
Negative
Negative
Positive
IMMUNIZATION RECORD (TO BE COMPLETED BY HEALTH CARE PROVIDER)
CONFIDENTIAL HEALTH REPORT
Page 5 of 7
CENTER FOR STUDENT HEALTH AND
PSYCHOLOGICAL SERVICES
1. Please perform a physical examination on the student. Note that this examination will also be used to allow students
to participate in intercollegiate athletics.
Select One
Description
Head, eyes, ears, nose, and throat
Lungs, chest, and breasts
Cardiovascular system
Abdomen and viscera (include hernia)
Musculoskeletal
Endocrine system
Genital and urinary system
Date of last PAP smear:
Skin and lymphatics
Neurologic
Student ID #
Student Name
Age
Weight
Height
Blood Pressure
Pulse
Vision:
Hearing:
Urinalysis:
Smoker?:
Right Corrected to Corrected to Left
Left
Right
Albumin Sugar HCT
Gender:
3. Is the student eligible to participate in
intercollegiate athletics? If not, why?
5. Is the student under care for a chronic
condition or serious illness? If yes,
describe and send a clinical report
so we may provide continuity of care
4. Did you review the student's clinical history as given by the student?
6. Describe any follow-up for the medical
staff of the Center for Student Health
and Psychological Services
Provider Name
Provider
Address
Provider Phone
Provider Signature
Licence #
Provider Fax
Exam Date (mm/dd/yyyy)
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Abnormal
Abnormal
Abnormal
Abnormal
Abnormal
Abnormal
Abnormal
Abnormal
Abnormal
Yes
No
System
Yes
No
2. In the space below, record and describe any abnormalities that you found during the examination.
Male Female
PHYSICAL EXAMINATION (TO BE COMPLETED BY PHYSICIAN, PHYSICIAN'S ASSISTANT OR
NURSE PRACTITIONER)
CONFIDENTIAL HEALTH REPORT
Page 6 of 7
CENTER FOR STUDENT HEALTH AND
PSYCHOLOGICAL SERVICES
Check one of the boxes below.
I have (for students under the age of 18: My child has):
had the meningococcal meningitis immunization within the past 10 years.
Date received (mm/dd/yyyy)
Which vaccine did you receive?
If you received the meningococcal vaccine available before February 2005 called Menomune, this vaccine's protection
lasts for approximately 3 to 5 years. You should consider revaccination with the new conjugate vaccine called Menactra
within 3-5 years after receiving Menomune.
read, or have had explained to me, the information regarding meningococcal meningitis disease. I understand the
risks of not receiving the vaccine. I have decided that I (my child) will not obtain immunization against
meningococcal meningitis disease.
MENINGITIS IMMUNIZATION
New York State Public Health Law requires that all college and university students enrolled for at least six (6) semester
hours or the equivalent per semester, or at least four (4) semester hours per quarter, to answer the questions below. No
institution shall permit any student to attend classes in excess of 30 days without complying with this law.
CONFIDENTIAL HEALTH REPORT
Page 7 of 7
CENTER FOR STUDENT HEALTH AND
PSYCHOLOGICAL SERVICES
Linda Dragon
Center for Student Health and Psychological Services
101 Broad Street
Plattsburgh, NY 12901, USA
Fax: (518) 564 - 2188. For any questions, please call: 518-564-2187 or e-mail: linda.dragon@plattsburgh.edu.
In order to provide any necessary emergency care for students and to protect the physicians and institutions
involved, it is required that you sign the consent for emergency treatment below. We promise to make every effort to
immediately notify parents when serious accidents or illnesses come to our attention. However, since students often
attend this university from great distances, this may be slow or even impossible by phone. We appreciate your
cooperation.
(your name full name)
hereby authorize the medical staff of the State University of New York at Plattsburgh, upon consulting with a practicing
physician or surgeon, to exercise for me and on my behalf, all rights and duties with reference to consenting appropriate
medical, psychiatric, and surgical treatment, anesthetics, medicines, and hospitalization, including care and treatment by
any hospital/staff surgeon, physician, or radiologist that they deem necessary for the emergency care of my
Completed report should be sent mailed or faxed to:
I , by the authority vested in me as
of
(parent or legal guardian)
(student's full name)
(e.g.: son,sister, nephew, etc)
Date (mm/dd/yyyy)
Student's signature
FOR PARENTS OR GUARDIANS OF STUDENTS UNDER 18 YEARS OF AGE
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Completed 24 July 2020

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