Fillable INTERNATIONAL STUDENT MEDICAL HISTORY (Campbellsville College)

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INTERNATIONAL STUDENT MEDICAL HISTORY (Campbellsville College)

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INTERNATIONAL STUDENT
MEDICAL HISTORY
STUDENT INFORMATION
Last name: First: Middle:
Preferred Name:
Marital status? Single Married Divorced Widowed
Citizenship:
Birth date:
/ /
Age:
Sex:
M F
City:
Phone Number:
( )
P.O. box:
Country:
State:
Postal Code:
Year you will begin your studies ____________________ What term are you applying for? Fall (August) Spring (January)
What program will you be entering? ESL Undergraduate Graduate
MEDICAL HISTORY
Do you have any special needs
that we should be aware of?
Visual
Hearing
Physical
Learning Disability
Please check if you have had or
have any of the following:
Allergies Asthma Diabetes Dietary Problems
Epilepsy/ Convulsive Disorder Kidney Stones/Infection Heart Problems
Hypertension Injuries Emotional/Mental Problems
Your Physicians Name:
Physicians Phone:
Please list any medications you are
currently taking:
1. ____________________________________ 4. ____________________________________
2. ____________________________________ 5. ____________________________________
3. ____________________________________ 6. ____________________________________
IN CASE OF EMERGENCY
Name of primary contact :
Relationship to you:
Phone:
( )
Name of secondary contact:
Relationship to you:
Phone:
( )
I authorize Campbellsville University to contact the above named individual(s) in the event of an emergency concerning me and/or any members of
my immediate family.
______________________________________________________________________________ ___________________________________
Student signature Date
CONSENT OF EMERGENCY CARE
I do hereby give and grant to Campbellsville University and its Professional Staff, my consent to perform necessary emergency care procedures. They
may use their judgment in securing medical aid and/or emergency transportation. I give and grant to any medical doctor or hospital my consent and
authorization to render such aid, treatment, or care as in the judgment of said doctor or hospital, which may be required as an emergency basis, in
the event I should be injured or stricken ill while under supervision of Campbellsville University personnel.
______________________________________________________________________________ __________________________________
Student Signature Date
______________________________________________________________________________ __________________________________
Parent/Guardian Signature (Required if student is under 18 years of age) Date
Tuberculosis (TB) Screening Questionnaire
Please answer the following questions:
Have you ever had a positive TB skin test? Yes No
Have you ever had close contact with anyone who was sick with TB? Yes No
Were you born in one of the countries listed below and arrived in the U.S. within the
past 5 years? Yes No
If yes, please list the country _____________________________________________
Have you ever lived in or traveled to/in one or more of the countries listed below? Yes No
If yes, please list the countries: ___________________________________________________________________________
Countries with Estimated or Reported High Tuberculosis Incidence
Afghanistan
Algeria
Angola
Anguilla
Argentina
Armenia
Azerbaijan
Bahamas
Bahrain
Bangladesh
Belarus
Belize
Benin
Bhutan
Bolivia
Bosnia &
Herzegovina
Botswana
Brazil
Brunei
Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Central African
Rep.
Chad
China
Colombia
Comoros
Congo
Congo DR
Cote d’Ivoire
Croatia
Djibouti
Dominican
Republic
Ecuador
Egypt
El Salvador
Equatorial
Guinea
Eritrea
Estonia
Ethiopia
Fiji
French
Polynesia
Gabon
Gambia
Georgia
Ghana
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
India
Indonesia
Iran
Iraq
Japan
Kazakhstan
Kenya
Kiribati
Korea-DPR
Korea-Republic
Kuwait
Kyrgyzstan
Lao PDR
Latvia
Lesotho
Liberia
Lithuania
Macedonia-TFYR
Madagascar
Malawi
Malaysia
Maldives
Mali
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova-Rep.
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
New Caledonia
Nicaragua
Niger
Nigeria
Niue
N. Mariana
Islands
Pakistan
Palau
Panama
Papua New
Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russian
Federation
Rwanda
St. Vincent &
The Grenadines
Sao Tome &
Principe
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Singapore
Solomon
Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Syrian Arab
Republic
Swaziland
Tajikistan
Tanzania-UR
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Wallis & Futuna
Islands
W. Bank & Gaza
Strip
Yemen
Zambia
Zimbabwe
Tuberculosis Testing Record
If you have answered YES to any of the above questions, a PPD (Mantoux) skin test is required, even if you have had
the BCG vaccination in the past. If you arrive to campus without having received a TB test you will be required to take the test
in Campbellsville and cover all expenses related to the test. This test will not be covered by the CU provided medical insurance.
Your Health Care Provider must complete and sign below as proof of test:
TB (PPD) Skin Test
Date Administered:
_______________________
Date Test Read:
_______________________
Skin Test Result
(size of induration)
_______________________
Mm
_______________________
Signature of Health Care
Provider
Chest X-Ray
Required if TB skin test is Positive
_______________________
Date of X-ray
Result: NEG POS
(attach copy of written
report)
Health Care Provider
_______________________
Signature
_______________________
Treatment
(if any)
REQUIRED VACCINES
MMR Vaccination* (measles, mumps, and rubella combined)
If before 1970, please have the vaccine repeated before entering the university.
Date of 1
st
shot:
_____ / _____ / _____
Date of 2
nd
shot:
_____ / _____ / _____
Tetanus Shot*
If longer than 10 years, please update tetanus before entering the university.
Date of last shot: _____ / _____ / _____
Meningitis Vaccine (recommended but not required)
Hepatitis B Vaccine (recommended but not required)
*A photocopy of immunization records MUST be included. Campbellsville University recommends that students get the meningitis
vaccine from their personal physician or local health department.
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INTERNATIONAL STUDENT MEDICAL HISTORY (Campbellsville College)

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Completed 19 August 2020

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