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Wilkes University Health & Wellness Services Passan Hall (Wilkes University)

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  • 40 check-boxes
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File type: PDF

U.S.A. forms for Wilkes University

BROWSE WILKES UNIVERSITY FORMS

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WILKES EMAIL - _______________________________WIN #_____________
Wilkes University Health & Wellness Services
Passan Hall - 1st Floor
84 W. South St.
Wilkes-Barre, PA 18766
Health History
Telephone - (570) 408-4730 Fax - (570) 408-7873
The primary purpose of this form is to assure that immunizations are current and to
provide a historical basis for the provision of health care through the Student Health Service.
Information is CONFIDENTIAL and will not be released without student’s written consent
and will not affect admission status.
Please complete this portion before going to your physician for examination.
_________________________________________________________________________________________
LAST NAME (print) FIRST MIDDLE
_________________________________________________________________________________________
HOME ADDRESS (No. & Street) CITY or TOWN STATE ZIP CODE
_________________________________________________________________________________________
HOME TELEPHONE NO. STUDENT CELL PHONE NO. SOCIAL SECURITY NO.
_________________________________________________________________________________________
SEX DATE OF BIRTH MARITAL STATUS
EMERGENCY INFORMATION:
NAME_______________________________________________RELATIONSHIP____________________________
ADDRESS__________________________________________________________________________________
CELL PHONE__________________________________________________HOME PHONE_________________________________________________________
ACCIDENT AND/OR HEALTH INSURANCE:
• The University as of the 2013-14 academic year will require all resident students and athletes to have some
form of health insurance and a COMPLETED health form before they are able to have access to university
owned housing.
• The University requires proof of insurance coverage by each student prior to the start of the academic year.
Please copy both sides of your insurance card and include in the envelope with the heath form.
PLEASE COPY BOTH SIDES OF YOUR INSURANCE CARD AND RETURN WITH THE HEALTH
FORM
PERSONAL MEDICAL HISTORY
Are you being treated for any medical condition? Yes___ No___
Specify:_______________________________________________________________________
Have you ever had surgery? Yes___ No___
Specify:_______________________________________________________________________
Do you have or have ever been told that you have a heart condition? Yes___ No___
Specify:_______________________________________________________________________
Have you ever had a head injury with a loss of consciousness? Yes___ No___
Date:____________________ Was a CAT scan done?________________________
Are you ALLERGIC to ANYTHING - including prescription medications, over the counter
medications, foods, insects, inhalants? Please specify allergy or reaction.
Allergic to:_____________________________________________________________________
Reaction: ______________________________________________________________________
CONFIDENTIALITY:
As a consumer of our services, confidentiality is your right, except where limited by the ethics of our practice
and the law. Should you choose to have information released about you to a third party, this will
be done only with your consent. Please sign to verify acknowledgement of this information.
Student Signature_________________________________________Date______________________
AUTHORIZATION FOR TREATMENT:
I hereby authorize the Wilkes University Health Services to treat any illness or injury as deemed
necessary by the staff. In the case of a serious medical emergency, please be advised that the student will be
transported to the nearest health care facility. During a medical emergency, every effort will be made
to notify the contact person listed on the health history form. All bills incurred will be the responsibility
of the student.
Student Signature__________________________________________Date_____________________
If involved in Intercollegiate Sports, can this form be used as part of your physical exam? Yes__No__
Student Signature__________________________________________Date_____________________
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Physical Examination
This section is to be completed by physician/clinician
.
__________________________________________________________________
LAST NAME (print) FIRST MIDDLE SEX
Blood Pressure_____/_____ Pulse_________ Height________Weight ________
SYSTEMS REVIEW
Normal Abnormal Describe
Abnormalities
Skin ________________ _______________ __________________
HEENT ________________ _______________ __________________
Lymph Nodes ________________ _______________ __________________
Neck ________________ _______________ __________________
Heart ________________ _______________ __________________
Lungs ________________ _______________ __________________
Back ________________ _______________ __________________
Breasts ________________ _______________ __________________
Abdomen ________________ _______________ __________________
Genitalia (Male) ________________ _______________ __________________
Pelvic (Female) ________________ _______________ __________________
Rectal ________________ _______________ __________________
Musculoskeletal ________________ _______________ __________________
Neuro/Psych ________________ _______________ __________________
Is the patient on any medications? Please list_______________________________
___________________________________________________________________
Does the patient have any known allergies? Please List ______________________
___________________________________________________________________
Recommendations for physical activity (college sports, PE, Intramurals, ROTC)
Unlimited_______________________ Limited_________________________
Explain:____________________________________________________________
Is this patient now under treatment for any medical condition?_________________
___________________________________________________________________
Is this patient now under treatment for any emotional condition?_________________
Do you have any recommendations regarding the care of this patient?_____________
____________________________________________________________________
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IMMUNIZATION RECORD
NAME_______________________________________________________________________________
Last First M.I.
Date of Birth_____________________________________ SS#__________________________________
Month/Day/Year
REQUIRED IMMUNIZATIONS
MUST BE UPDATED AS SPECIFIED BELOW
To be completed by a Health Care provider (Dates must include month and year.)
Tetanus Toxoid Diphtheria & Acellular Pertussis Vaccine (TDAP) (within 10 years) _________________
Varicella – Dose 1 ________________Dose 2 ______________Had disease date ___________________
Polio (year of basic series) _______________________________________________________________
Measles/Mumps/Rubella 1st dose____________________2nd dose_______________________________
Mantoux test (within year) Date_____________________ Result_________________________________
If Mantoux positive - chest X-ray results required
Hepatitis B Series____________________ _______________________ ________________________
PA State law requires that college students be advised of the risks associated with meningococcal disease
and the availability/effectiveness of the vaccine www.cdc.gov/meningitis/index.html. All students living in
university owned housing must provide proof of vaccination or a written waiver before occupancy will be
permitted.
Two doses of MCV4 are recommended for adolescents 11 through 18 years of age: the first dose at 11 or 12 years of age,
with a booster dose at age 16. If the first dose (or series) is given between 13 and 15 years of age, the booster should be
given between 16 and 18. If the first dose (or series) is given after the 16th birthday, a booster is not needed.
Student will be living in university owned housing Yes______ No______
Meningococcal Vaccine Dose 1 ________________________Dose 2 _____________________
Student has been advised of the risks associated with meningococcal disease, the
availability/effectiveness of the vaccination and has decided not to receive the vaccination. At this time, the
student waives receipt of meningococcal vaccine.
Reason________________________________________________________________________________
Student Signature____________________________________________Date_______________________
HEALTH CARE PROVIDER
Print Name_____________________________Signature____________________________Date__________
Address_________________________________________________________________________________
Telephone:(____)-_______________________________Fax:(____)-____________________________
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Wilkes University Health & Wellness Services Passan Hall (Wilkes University)

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Completed 18 September 2020

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