Student Health Form - Bloomsburg University

Student Health Center
Bloomsburg University
Student Health Form
Student Health Form
Return Pages 1, 2, and 3 to:
Bloomsburg University Student Health Center
Room 324 Kehr Union Building
Bloomsburg University of PA
400 East Second Street
Bloomsburg, PA 17815
OR
FAX to 570-389-3417
****Please keep a copy of this health form at home for your records****
Revised June 2012

Student Health Form
ALL INFORMATION MUST BE IN ENGLISH
Nursing Students Check Here Admission for: Spring Summer Fall 20________
International Exchange Students Check Here; Home Country: _______________________________
____________________________________________ _________________ ____________
Last Name First MI BU ID Number Birthdate
_________________________________________ _______ - _______ - ___________
Home Address Cell Phone #
_________________________________________ ____________________________
E-mail Address
REQUIRED IMMUNIZATION INFORMATION
The dates of the following immunizations (numbers 1 through and including 4) must be listed.
Without these dates, your health form status will be considered incomplete which will prevent
you from scheduling and/or registering for classes. Contact the following sources for your
immunization records: family doctor, high school, Dept. of Health, Baby book with immunization records.
1. MMR (Measles, Mumps, Rubella)
(Two doses, given 4 weeks apart, after the first birthday, are required for students born after 1956.)
Positive titers are also acceptable.
A. MMR I: MMR II: , OR
B. Titer Date: Rubeola: Pos. Neg. Mumps: Pos. Neg. Rubella: Pos. Neg.
2. VARICELLA (Chickenpox)
(A history of chickenpox, a positive varicella titer, or two doses, given 4 weeks apart, after the first birthday.)
A. Year of Disease: , OR
B. Vaccination Dates: Dose #1 Dose #2 , OR
C. Titer Date: Positive Negative
3. TETANUS, DIPHTHERIA, PERTUSSIS (Tdap or Td)
Tetanus is given routinely every 10 years. Tdap is given one time as a replacement vaccination to protect you
against Pertussis (whooping cough).
Tdap (Boostrix or Adacel) Date: _____________________ Last Td Date: ____________________
4. HEPATITIS B:
Three doses, given at 0, 1 and 4-6 months apart, or a positive Hepatitis B surface antibody titer.
A. Dose #1: Dose #2: Dose #3: , OR
B. Titer Date: Positive Negative
5. Recommended, but not required:
Hepatitis A #1 _______ #2 _______ Gardasil #1 _________ #2 __________ #3 _________
STUDENT HEALTH CENTER OFFICE USE ONLY
Undergraduate Student Graduate Student
Hx & Immun. Complete? Yes No Date Notice Sent:____________ HC.Staff:______ Hx & Immun. Complete? Yes No Date Notice Sent:_____________ HC Staff:______
Meningitis Vaccine: V W N (Circle One) Meningitis Vaccine: V W N (Circle One)
Incomplete for: MMR 1 2 Varicella 1 2 Tdap or Td Incomplete for: MMR 1 2 Varicella 1 2 Tdap or Td
Hep B 1 2 3 TST:_______ Hx:______ Hep B 1 2 3 TST:_______ Hx:______
Override: __________________________________________________________________ Override: __________________________________________________________________
Page 1

Health Form (Continued)
Tuberculin Skin Test (TST) by Mantoux Method
All International students and Nursing students (beginning with sophomore year) must have a Tuberculin skin test (TST by
Mantoux method only) within the past 6 months. FOR ALL OTHER STUDENTS, TESTING IS OPTIONAL. International
Students, if you have received BCG vaccine, please indicate year that you received this vaccine: ____________
Date of Test ___________ Date of Reading ____________ Negative _____ mm Positive ______ mm
If test Positive: Chest X-ray: Date ____________________ Results: Negative X-ray Positive X-ray
(10mm or greater)
Any Treatment _________________________________________________________________________________________
Meningitis Vaccination Information and Waiver
Students living in campus housing are required by law (Senate bill 955—06-25-2002) to show evidence of
meningitis vaccination or sign a waiver stating that through informed consent they refuse this vaccine. Please read
the following information regarding Meningitis. Currently there are safe and effective vaccines available to protect
against the most common subtypes of meningitis bacteria. As with any vaccine, protection may not be 100%. This
vaccine does not protect against viral meningitis.
If you have received Menactra, Menveo, or Menomune (all 3 are acceptable to vaccinate against meningitis), please
indicate the vaccination date at the bottom of this page. The meningitis vaccine should be repeated if it was given
more than 3 years ago, or if you were under 16 years of age when you received your last vaccine. If you do not wish
to receive the meningitis vaccine, please indicate this decision by signing the waiver at the bottom of this page.
Please print your name clearly following your signature.
General Information
College students are at increased risk for meningitis, a potentially fatal bacterial infection. Freshmen living in college residence
halls have a six-fold increased risk for the disease. Statistics show that 65 – 70% of cases of meningococcal disease in college
students are vaccine preventable.
What is meningitis: Meningitis is an inflammation of the protective membranes covering the brain and spinal cord. The
inflammation may be caused by infection from viruses, bacteria or other microorganisms. Bacterial meningitis can be readily
spread from person to person and, if not detected early, permanent brain damage, organ failure and/or death may occur.
How is it spread? Bacterial Meningitis is spread by close contact with an infected person. Modes of transmission include (but
not limited to) coughing, sneezing, kissing, and/or sharing items like utensils, cigarettes, and drinking glasses.
What are the symptoms? Initially, flu like symptoms can be followed by high fever, severe headache, stiff neck, rash, nausea,
vomiting, confusion, and eventually coma.
Who is at risk? Students in Residence Halls or groups living together in apartments, etc., are the students most at
[increased] risk, probably because the bacteria is spread quickly wherever groups of susceptible young adults congregate. Other
students should also consider vaccination to reduce their risk for this disease.
This Section MUST BE COMPLETED BY ALL STUDENTS LIVING IN CAMPUS HOUSING:
Date of most recent meningococcal immunization:
Menactra Menveo Menomune
Waiver: I have read and reviewed the information regarding meningococcal disease. I am fully aware of the risks associated
with this disease and of the availability and effectiveness of the meningococcal vaccine. I knowingly decide NOT to receive
the vaccine at this time.
________________________________________________ __________________________________________________ ____________________
Signature of Student Print Name Date
Page 2

Allergies to Medication(s): Specify Type of Reaction:
Allergies to Food and Additives: Specify type of Reaction:
Self Reported Health History
_______________________________________________________ _____________________ _________________
Last Name First Name M.I. BU ID Number Birth Date
Personal History
Have you been treated or hospitalized for:
(Check All that Apply) ()
Yes No
Anxiety
Depression
Are you allergic to Latex? Yes No Bipolar Illness
Check All that Apply ()
Hyperactivity/ADD
Have you had or currently have:
Yes No
Heart Disease or Rhythm Abnormalities
(Specify):
Eating Disorders (Specify):
Reactive Airway Disease (Asthma) Surgical Procedures:
Seasonal Allergies
(Check All that Apply) ()
Yes No
Recurrent sinus infections/head colds
Appendectomy (Date)
Recurrent chest colds/bronchitis Tonsillectomy (Date)
High or Low Blood Pressure (circle one) Wisdom Teeth Extraction (Date)
Latent Tuberculosis (TB) or Active TB Other Surgeries
Diabetes
Past history of Mononucleosis
History of Kidney Disorders
Past/Present treatment for Tumor/Cancer
(Specify):
Epilepsy/Seizure Disorder Do you have a history of the following:
Past History Bone/Joint Disease or Injuries
(Specify):
(Check All that Apply) ()
Yes No
Tobacco Use
Problems with Diarrhea
Problems with Constipation
History of Hepatitis (Specify):
History of Rheumatic Fever
Recurrent Headaches (Specify):
Past History of Cold Sores
List Past Hospitalizations and dates:
Alcohol Use
Recreational Drug Use
Performs Regular Self-Breast Exams
Performs Regular Testicular Exams
Present or past skin conditions (Specify):
Chickenpox Disease Date (Year) ____________
Family History Have any of your relatives had any of the following?
Yes No Relationship Yes No Relationship
Tuberculosis Cancer (specify)
Diabetes Asthma
Kidney Disease Epilepsy
Heart Disease Alcoholism/Drug Abuse
List any medications you take on an ongoing basis with exact dosage. (Please include daily herbal supplements and birth control methods)
Medications 1.
(List Dosage): 2.
3.
Additional Information _________________________________________________________________________________
_____________________________________________________________________________________________ Page 3