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Randolph-Macon College Student Health Center P.O. Box 5005 (Randolph-Macon College)

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Randolph-Macon College
Student Health Center
P.O. Box 5005
Ashland, VA 23005
Phone: 804.752.3041
Email: studenthealth@rmc.edu
Checklist for Students and Parents
(This page is for you to keep)
1. Health History Records- Required for ALL students. (athletes, residential, commuters, and part-time)
Fall Admission Due: August 1st Spring Admission Due: January 31
st
2. Upload the completed Health History Record/Form to your secure patient portal.
Do not mail, email or fax the form. Patient portal: studenthealth.rmc.edu
If the student is under 18 at the time of check-in please complete and upload the Authorization to Treat a Minor
**Make and Keep a copy of this form for your personal records**
3. Print your full name at the TOP of Pages 2 and 3.
4. VARSITY ATHLETES: Please be sure to take this form and your required athletic forms (found in the
athletic portal) to your medical provider at the same time. This Health Form must be uploaded to the
student health portal: studenthealth.rmc.edu and the athletic forms must be uploaded to the athletic
portal: rmcsportsmed.e-ppe.com
5. Students not in compliance with all immunization requirements and TB screening for
entrance to Randolph-Macon College will be referred to the Dean of Students for Failure to
Comply with College Policy and Required forms.
6. Immunizations:
REQUIRED for ALL students (including commuters):
□ MMR (measles, mumps, rubella): 2 doses or equivalent individual doses of each
□ Tetanus booster (within past 10 years)
□ Polio Series
□ Hepatitis B-- completed series or signed waiver declining vaccine
□ Meningococcal Meningitis (must have booster after 16 years of age)—or signed
waiver declining vaccine
STRONGLY RECOMMENDED:
□ Varicella (chickenpox) or history of disease
□ Hepatitis A
□ Human Papilloma Virus (Gardasil--series of 3 injections)
7. Health Insurance: We strongly recommend all students have adequate health insurance
coverage while living in Richmond, VA. Students should always carry a copy of the insurance
card.
8. First Aid Supplies: Recommended items to bring with you to campus: digital thermometer,
acetaminophen, ibuprofen, cold medications, Band-Aids, topical antibacterial cream, a reusable
cold pack, and sunscreen.
_____________________________________________________________________________________________________________________
________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
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For Office Use Only: Completed____________
Notes: __________________________________
Student Health Center
PO Box 5005 Ashland VA 23005
Phone: (804)752-3041
Email: studenthealth@rmc.edu
Patient Portal: studenthealth.rmc.edu
HEALTH HISTORY RECORD – 2020-2021
• Upload Health History Record pages directly to the Patient Portal: studenthealth.rmc.edu
DUE: August 1 (Fall Admission) January 31 (Spring Admission)
• Do not include forms for other departments in your upload. Do not mail, email or fax this form.
• Varsity Athletes must upload this Health History Form into the student portal: studenthealth.rmc.edu AND
upload the athletic forms (found in the athletic portal) into the athletic portal: rmcsportsmed.e-ppe.com
Name:_________________________________________________________________ Date of Birth: ____/___/____
Last First Middle mo day year
Permanent Address:_______________________________________________________________________________
Street City State /Country Zip Code
Country of Birth: ____________________ Email: ________________________________________________________
Home Phone: ________________________ Student’s Cell Phone:______________ Student ID #:____________
Preferred Name
:______________________ □ Male □ Female Expected R-MC Graduation Date:__________________
MEDICAL HISTORY (Please check all that apply and explain any "Yes" answers below)
Yes No Yes No Yes No
□ □ Allergies (annual/seasonal) □ □ Eating Disorders □ □ Rheumatic Fever
□ □ Anemia □ □ Gastrointestinal Problems □ □ Tuberculosis
□ □ Asthma/Exercise-Induced Asthma □ □ Gynecological Problems □ □ Sexually Transmitted Diseases
□ □ Bone/Joint Disorder □ □ Frequent Headaches □ □ Elevated Cholesterol
□ □ Cancer □ □ Heart Disease □ □ High Blood Pressure
□ □ Chicken Pox □ □ Hepatitis/Liver Disease □ □ Frequent Throat Infections
□ □ Circulatory Problems/Blood Clots □ □ Kidney/Urinary Problems □ □ Frequent Ear Infections
□ □ Convulsions/Seizures/Epilepsy □ □ Mental Health
(depression/anxiety/other) □ □ ADD/ADHD
□ □ Diabetes □ □ Mononucleosis □ □ Other – Explain Below
Current Weight:__________ Current Height:_________
Current Diagnosis, Medications and Dosage:____________________________________________________________________________________
Allergies: medication/foods, etc. (include reaction) _____________________________________________________________________________
Significant illness/hospitalization/surgery (include dates):________________________________________________________________________
History of psychiatric/psychological condition (ex: anxiety 1/12-present)____________________________________________________________
Health Insurance Information:
Person to be notified in case of emergency: Name:____________________________ Relationship: ____________________________
Address: _________________________________________ Preferred Phone Number:_____________________________
Insurance Company Phone Number
Address City State Zip
Name of Policy Holder Individual ID ID/Group #
1 of 4
Student's Full Name:_________________________________________________________________________________________
PLEASE PRINT
Tuberculosis Risk Self-Assessment (TBRA)
Student completes upon entrance or within 6 months of re-entrance to the College
1. Have you ever had a positive tuberculosis (TB) test? NO _____ YES _____ * If you have had a positive TB test in the past,
you must submit documentation of the positive test, including chest x-ray report and treatment records. Further testing may not
be required.
2. Do you have any of the following signs or symptoms of active TB disease? NO _____ YES _____
o Unexplained fever/chills for more than 1 week
o Persistent cough of unknown etiology for more than 3 weeks
o Cough with bloody sputum
o Night sweats
o Unexplained weight loss
o Unexplained fatigue
3. Do any of the following situations apply to you? NO _____ YES _____
o Close contact with a person known or suspected to have TB
o Use of any illegal injectable drugs
o At risk for Human Immunodeficiency Virus (HIV) infection
o Volunteered, resided, or worked in a healthcare facility or congregate living setting
(homeless shelter, nursing home, or correctional facility) for longer than 1 month
o History of silicosis, diabetes, renal disease, blood disorders or cancer
o History of gastrectomy, jejunoilieal bypass, or chronic malabsorptive condition
o History of a solid organ transplant (kidney, heart, liver)
o Immunosuppressive therapy, such as prolonged corticosteroid therapy, chemotherapy
Or TNF-antagonist medications (Humira, Embrel, Remicade)
o Are less than 10% of normal body weight or malnourished
4. Within the past 5 years, have you traveled to or lived in any of the following areas for more than one month? NO __YES ___
Africa, Asia, Central America, Cuba, Dominican Republic, Eastern Europe, Haiti, India and other Indian subcontinent nations, Middle
East (except Egypt, Saudi Arabia, Jordan, Lebanon, UAE), Portugal, South America, South Pacific (except Australia and New Zealand).
Student Signature (or guardian if under 18) :______________________________ Date:______________________
If you answered “yes” to any question above, TB testing is required.
If you have questions regarding testing for TB please contact the Student Health Center (804) 752-3041. Your options for testing are as
follows:
1. Have the test done as soon as possible with your health care provider, prior to coming to the College. It may take several
weeks for the results to be sent to us, do not delay testing. Submit a copy of the written report to the Student Health Center.
2. Have the test done at the SHC during Orientation Week. The SHC will be open 8:00 am until 4:00 pm Monday - Friday. The
cost of the test will be billed to your student account.
Test Used:___________________Date Placed:______________Date Read _______________________
Result: _______ Positive ________Negative CXR indicated _____YES ______NO
Health Care Provider Name: ____________________________________________________________
Signature_____________________________ Phone:___________________________________
2 of 4
___________________________________________________________________________________________
Student's Full Name: ___________________________________________________________________________
PLEASE PRINT
All immunization dates must be verified by a health care provider or public health official with full name, signature, title and
complete address and phone number.
Information must be in English
Virginia State Law and Randolph-Macon College
Require the Following Immunizations
A) MMR (Measles, Mumps, Rubella)
Two doses live vaccine required at or after 12 months of age, at least one month apart
If vaccinated separately: Measles Dose #1 ____/____/___
Mumps Dose #2 ____/____/___
Rubella Dose #1 ____/____/___
Dose #1 _____/____/____
Dose #2 _____/____/____
Dose # 2 ____/____/____
Dose #2 ____/____/_____
B) TETANUS/DIPHTHERIA/PERTUSSIS (Tdap) or TETANUS/DIPHTHERIA (TD)
This booster date must be within last 10 years: _____/____/____
C) MENINGOCOCCAL VACCINE (ACYW-135)
This booster date must be after student turns 16: _____/____/____
D) HEPATITIS B VACCINE
(3 doses required)
E) POLIO VACCINE
a. HEPATITIS A VACCINE
2 doses vaccine given at 0, 6-12 months
b. HUMAN PAPILLOMAVIRUS VACCINE (HPV)
3 doses at 0, 2, and 6 month intervals
(or sign waiver – see next page)
Dose #1 _____/____/____
Dose #2 _____/____/____
Dose #3 ____/____/____
(or sign waiver – see next page)
Last Dose _____/_____/___
RECOMMENDED IMMUNIZATIONS
Dose #1_____/____/____
Dose #2_____/____/____
Dose #1_____/____/____
Dose #2_____/____/____
Dose #3_____/____/____
Mo Day Yr
c. VARICELLA VACCINE *STRONGLY RECOMMENDED* Dose #1_____/____/____
Two doses of vaccine one month apart Dose #2_____/____/____
➠Verified by :
Mo Day Yr
Or History of Disease ___/____/_____
Health Care Provider’s Signature: _________________________________
Name Printed:__________________________________________________
Address: ______________________________________________________
Phone: ________________________________________________________
3 of 4
_________________________________________________________________ ___________________________________
_________________________________________________________________ ___________________________________
Student's Full Name: ___________________________________________________________________________
PLEASE PRINT
WAIVER DOCUMENT
INFORMATION REGARDING HEPATITIS B AND MENINGOCOCCAL
MENINGITIS DISEASE AND IMMUNIZATION
In compliance with Virginia state law, Randolph-Macon College requires that all incoming full-time
students be vaccinated against meningococcal disease and Hepatitis B disease OR sign a waiver indicating
they have received information about these diseases, the availability and effectiveness of the vaccines and
choose not to be vaccinated.
HEPATITIS B is a serious infection of the liver caused by the Hepatitis B virus. The Hepatitis B virus (HBV)
may cause lifelong infection, cirrhosis of the liver, liver cancer, liver failure and death. Hepatitis B is
transmitted through infected body fluids such as blood, semen, and vaginal secretions; infection may occur
through mucous membranes and broken skin. Most commonly, Hepatitis B is transmitted by sexual contact. It
may also be spread by exposure to blood through contact sports, repeatedly sharing an infected person’s
razor, toothbrush, or earrings, travel to a high-risk area, use of illicit injectable drugs or through contaminated
needles use for tattooing or piercing. The Hepatitis B vaccine is safe and effective. The vaccine is generally a
series of three doses given over a period of 6 months, although the series never has to be re-started if the
schedule is interrupted.
HEPATITIS B VACCINE WAIVER
I have reviewed the information provided on the risks associated with Hepatitis B disease, and the effectiveness of any vaccine
against Hepatitis B disease and I choose not to be vaccinated at this time.
Signature of student or Legal Guardian if under age 18 Date
MENINGOCOCCAL DISEASE is a potentially fatal bacterial infection caused by the organism Neisseria
meningitis. Although meningococcal disease is relatively rare, the initial flu-like symptoms may make
diagnosis difficult. The disease may lead to brain damage, vital organ failure, permanent disability or death.
Studies indicate college students living in residence halls, especially freshmen residents, are at increased risk
of infection.
MENINGOCOCCAL VACCINE WAIVER
I have reviewed the information provided on the risks associated with Meningococcal disease, and the effectiveness of any
vaccine against Meningococcal disease and I choose not to be vaccinated at this time.
Signature of student or Legal Guardian if under age 18 Date
4 of 4
______________________________________________________________________________
_______________________________________________________________________________
AUTHORIZATION FOR CONSENT TO TREATMENT OF MINOR
(I), (We), the undersigned, parent(s) or legal guardian of _____________________
a minor, do hereby authorize Randolph-Macon College Student Health
as agent(s) for the undersigned to consent to any diagnostic testing, examinations, anesthetics medical or
surgical diagnosis or treatments and/or hospital care which is deemed advisable by and is to be rendered under
the general or special supervision of any licensed medical provider.
It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care
being required but is given to provide authority and power on the part of our aforesaid agent(s) to give specific
consent to any/all such diagnosis, treatment or hospital care which the aforementioned medical provider(s) in
the exercise of his best judgment may deem advisable.
This authorization shall remain effective until the Student becomes of age at 18.
Date:____________________ Parent:___________________________________
Legal Guardian:____________________________
Birthdate:________________
Allergies to Drugs or Foods:_______________________________________________________
Current Medications:_____________________________________________________________
Current Medical or Mental Health Problems:___________________________________________
Student’s Health Care Provider:_____________________ Provider’s Phone#_________________
Father/Guardian Signature Home Phone Business Phone
Mother/Guardian Signature Home Phone Business Phone
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Randolph-Macon College Student Health Center P.O. Box 5005 (Randolph-Macon College)

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Completed 23 July 2020

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