MEDICAL INFORMATION FORM - Columbus College of Art & Design

MEDICAL INFORMATION FORMWWW.CCAD.EDUTHIS FORM MUST BE RETURNED TO:STUDENT AFFAIRS OFFICE, COLUMBUS COLLEGE OF ART & DESIGN60 CLEVELAND AVE., COLUMBUS, OH 43215P: 614.222.4044, F: 614.222.4034All students MUST SUBMIT this form and immunization records. Enrollment fornext semester will not be permitted if you lack proof of mandatory vaccinations.Please be aware that the College does not provide on-campus medical services.A physical examination, WHILE NOT MANDATORY, is highly recommended as avital supplement to your health history.Important: This form DOES NOT serve as official notification to the Collegeof a disability for purposes of ADA or Section 504 of the Rehabilitation Act.If accommodations are requested, official documentation must be filed withDisability Services. Call 614.222.4004 for more information.INSTRUCTIONS:– The medical information forms (pages 1–3) are to be completed and signedby the student (or parent/guardian if appropriate).– All immunizations (page 4) must be up to date and the form signedby a health care professional. Official print-outs from health careproviders may be attached to the form in place of the signature.– If faxed from physician’s office, please check that all mandatoryimmunizations as listed are current.– All information must be provided in English.– Students seeking a medical/religious exemption to providing thisinformation must contact the Student Affairs Office at 614.222.4044.– Please make a copy of this record for your own files. Medical forms willbe held by CCAD for only 6 years from the date a student enters the college.After that, the medical form will be destroyed and no copies will be available.STUDENT INFORMATION (PLEASE PRINT CLEARLY)FULL LEGAL NAMECITIZENSHIPLAST FIRST MIDDLE INITIALEMAILHOME ADDRESSCITY /TOWN STATE ZIPSEX DATE OF BIRTH HOME PHONE # ( ) CELL PHONE # ( )STUDENT’S EMAILPARENT/GUARDIAN INFORMATIONNAME #1RELATIONSHIP TO STUDENTHOME PHONE ( ) CELL PHONE ( ) WORK PHONE ( )ADDRESS (IF DIFFERENT)EMAILNAME #2RELATIONSHIP TO STUDENTHOME PHONE ( ) CELL PHONE ( ) WORK PHONE ( )ADDRESS (IF DIFFERENT)EMAILEMERGENCY CONTACT (OTHER THAN ABOVE)NAMERELATIONSHIP TO STUDENTADDRESSHOME PHONE ( ) CELL PHONE ( ) WORK PHONE ( )OVER

MEDICAL INFORMATION FORM (CONTINUED)PAGE 2 OF 4I GIVE PERMISSION FOR HEALTH CARE PROVIDERS TO ADMINISTER ANY MEDICAL OR DENTAL PROCEDURESTHAT ARE NECESSARY IN AN EMERGENCY.SIGNATURE OF STUDENTDATESIGNATURE PARENT/GUARDIANParent or guardian must sign if student is under 18 years old. In the event of serious illness or injury, every effort will be made to contact parent/guardian.DATEPRIMARY HEALTHCARE PROVIDERPRIMARY HEALTHCARE PROVIDER NAMETITLEADDRESS PHONE # ( )PRIMARY HEALTH INSURANCE COMPANYMEMBER’S NAMECARD / GROUP # PHONE # ( )FAMILY HISTORYAge State of Health Occupation If Deceased, Age at Death Cause of DeathParent/Guardian #1Parent/Guardian #2BrothersSistersPHYSICAL EXAMINATIONA physical examination, while not mandatory, is highly recommended as a vital supplement to your health history. We find that a physical exam prior tothe beginning of classes can help ensure a semester uninterrupted by absences due to illness. Including a copy of your physical examination report whenyou return these health documents is helpful to the College in the event of an emergency or other medical situation.

MEDICAL INFORMATION FORM (CONTINUED)PAGE 3 OF 4MEDICAL INFORMATIONPlease indicate whether or not you have experienced or been treated for any of the following (past or present).PERSONAL HISTORY Yes No Yes No Yes NoADHD Gallbladder disease ObesityRecurrent headaches Gum/dental disease Painful menstrual cycleAllergies Gynecological problems Panic attacksAnemia Hay fever Pneumonia historyAnorexia/Bulimia Head injury (unconscious) ProcrastinationAnxiety Heart problems Difficulty controlling drug/alcohol useArthritis or other joint problem Hepatitis/Jaundice Rheumatic fever/Scarlet feverAsperger’s or Autism High blood pressure Self-injury or self-harm (cutting)Asthma/Respiratory problems Hernia Sexually transmitted diseaseBack problems HIV-positive/AIDS ShynessBlind/Visual impairmentBipolar disorderSleep disorder (insomnia,apnea)Stomach/intestinal (ulcers,IBS)Sickle cellSkin problemBlood/Bleeding disorder Kidney disease/infections Speech disorderCancer/Tumor/Cyst Learning disability Suicide attemptChicken pox Low blood pressure Surgery–AppendectomyPregnancy Meningitis Surgery–TonsillectomySeizures or convulsions Mental illness Surgery–Other:Depression Migraine headaches Throat/Tonsil problemDiabetes Miscarriage Thyroid diseaseDifficulty sleeping Urinary tract infections Time management difficultyHearing loss/Deafness Nose bleeds/Sinus problem TuberculosisEmotional distress/Problems Fungal disease Other (list):Family/Friend commit suicideMononucleosis (“Mono”)Frequent coldsSchizophreniaCURRENT MEDICATIONS Yes No Yes No Yes NoADHD meds. (Adderall, Strattera,Ritalin, etc.)Over-the-counter pain relievers(Tylenol, Aleve, Aspirin, etc.)AntibioticsAnti-depressant (Zoloft, Paxil, Lexapro,Prozac, Effexor, Wellbutrin, etc.)Contraceptive/Birth controlAnti-psychotics (Zyprexa, Seroquel)Antihistamines, other allergymedicationAnti-anxiety (Xanax, Valium,Klonopin, etc.)Over-the-counter orprescription sleep medicineSteroidsInsulinVitamins/SupplementsThyroid medicationMood stabilizers (Lithium, Abilify, etc.)Inhaler for asthma or other breathing conditionOther (list):ALLERGIES Yes No Yes No Yes NoDust, pollen, mold Latex SulfaPenicillin Insect bites/Bee stings Other (list):AnimalsNutsPLEASE CHECK IF YOU WILL NEED ANY OF THE FOLLOWING WHEN YOU ENTER COLLEGE:REGULAR INJECTIONS PSYCHOLOGICAL COUNSELING CARE FOR AN EXISTING ILLNESS OR INJURYHAVE YOU CONSULTED OR BEEN TREATED BY A PSYCHIATRIST, CLINICAL PSYCHOLOGIST, OR COUNSELOR? NO YES YEARIF YOU HAVE BEEN HOSPITALIZED OR HAVE ANY MEDICAL PROBLEMS, PLEASE GIVE DETAILS

MEDICAL INFORMATION FORM (CONTINUED)PAGE 4 OF 4IMMUNIZATION RECORD (MANDATORY)PLEASE READ THIS FORM CAREFULLY AND PAY ATTENTION TO WHAT IS REQUIRED VERSUS WHAT IS OPTIONAL.CCAD requires all students to show proof of vaccination against Measles, Mumps, and Rubella (MMR), Tetanus (within last 5 years), and Hepatitis B (a series of2–3 injections). If none of the Hepatitis B series shots have been received prior to entering school, documentation of the first injection along with the dates of yourappointments for the second and third must be submitted with this form. Meningitis vaccination and a Tuberculosis test are highly recommended, especially if youwill be living in a residence hall environment. If documentation is not available for any vaccinations, you will need to have titer levels checked with your doctor andprovide that documentation. These requirements, although time consuming, are necessary for everyone’s protection.If faxed from your physician’s office, please check that all mandatory immunizations as listed below are current.Please do not wait until the last minute to schedule your necessary vaccinations.You will not be permitted to enroll for the next semester if you lack proof of mandatory vaccinations.MAKE A COPY OF THIS PAGE FOR YOUR OWN RECORDS. CCAD will only maintain this record for 6 years from the time a student enters theCollege. After that, it will be destroyed.STUDENT’S NAME (PLEASE PRINT)SEMESTER ENTERING CCAD (FALL/SPRING, YEAR)DATE OF BIRTHMANDATORY IMMUNIZATIONSMEASLES/MUMPS/RUBELLA (MMR) (MM/DD/YY)TETANUS/DIPHTHERIA (MUST BE WITHIN LAST 5 YEARS) (MM/DD/YY)HEPATITIS B #1 (MM/DD/YY) HEPATITIS B #2 (MM/DD/YY) HEPATITIS B #3 (MM/DD/YY)RECOMMENDED IMMUNIZATIONSMENINGITIS (MM/DD/YY)MANTOUX TEST FOR TB: DATE OF TEST (MM/DD/YY)DATE OF READING (MM/DD/YY)CHECK ONE: NEG POS MM INDURATIONIF TB TEST IS POSITIVE: CHEST X-RAY REPORT (CHECK ONE): NEG POS DATE (MM/DD/YY)IF CHEST X-RAY IS POSITIVE EXPLAIN TREATMENTREQUIREDOFFICIAL PRINT-OUTS FROM HEALTH CARE PROVIDERS MAY BE SUBMITTED ATTACHED TO THIS FORM IN PLACE OF THE SIGNATURE BELOW.SIGNATURE OF DOCTOR (OR OTHER PROFESSIONAL HEALTH CARE PROVIDER)ADDRESSPRINTED DOCTOR’S NAMEDATERETURN ALL PAGES OF THIS FORM TO:STUDENT AFFAIRS OFFICECOLUMBUS COLLEGE OF ART & DESIGN60 CLEVELAND AVE., COLUMBUS OH 43215P: 614.222.4044 F: 614.222.4034