MBU Office of Health Services ! 540-887-7095 ! fax: 540-887-7289 ! dduff@marybaldwin.edu

Part I: Health Form This form is to be completed by the incoming student by July 15.

Name:______________________________________________ Date of Birth:______________ Last First Middle MM/DD/YYYY

Social Security #:____________________ Marital Status: ( ) Single ( ) Married ( ) Divorced

Home Phone:_____________________ Cell Phone:_____________________

MBU Email:__________________________@marybaldwin.edu

Parent/Guardian’s Name:______________________________________________

Parent/Guardian Home Phone:___________________ Cell Phone:________________________

Class Entering: ( ) Freshman ( ) Transfer

Mailing Address:________________________________________________________________

Street City State Zip

In case of emergency, notify:______________________________________________

Day/Work Phone:________________________ Home/Night Phone:________________________

Relationship:____________________________

MBU Office of Health Services ! 540-887-7095 ! fax: 540-887-7289 ! dduff@marybaldwin.edu

PERMISSION FOR TREATMENT The University reserves the right to have any student admitted to the University examined by the University Physician/Nurse Practitioner. This form must be signed by the student. If the student is a minor (under 18 years old), this form must also be signed by the parent or legal guardian so that the appropriate diagnosis and treatment may be promptly carried out.

I certify that the information provided is true and complete to the best of my knowledge. I also understand that the information I have provided in the health record will be reviewed by the Health Center, Counseling and Psychological Services, and Head Athletic Trainer (*if applicable). I give permission to the University to furnish such procedures as may be deemed necessary by the Health Center staff, Counseling and Psychological Services staff, and the Health Athletic Trainer (if applicable) on my student’s behalf.

Student Signature:________________________________________ Date:__________________

Parent/Guardian Signature:_______________________________Relationship:________________

PROOF OF HEALTH INSURANCE (SUBMIT A COPY OF YOUR VALID CARD)

Insurance Company:___________________________________________________________

Insurance Subscriber’s Name:___________________________________________________

Insurance Policy Number:_______________________________________________________

Insurance Company’s Telephone Number:________________________________________

DISCLAIMER: IF OUT-OF-STATE INSURANCE, PLEASE VERIFY COVERAGE FOR VIRGINIA

MBU Office of Health Services ! 540-887-7095 ! fax: 540-887-7289 ! dduff@marybaldwin.edu

PERSONAL HEALTH HISTORY Please circle to indicate if you have ever been or are now being treated for the following:

ADD/ADHD

AIDS/HIV

ALCOHOLISM

ALLERGIES/HAY FEVER

ANEMIA

ANXIETY

ASTHMA

BLOOD DISORDERS

CANCER

CEREBAL PALSY

CYSTIC FIBROSIS

CHRONIC BRONCHITIS

CHRONIC KIDNEY CONDITION

CHRONIC INFLAM. BOWEL DISEASE

CROHN’S DISEASE

DENTAL DISEASE

DERMATOLOGICAL DISORDERS

DEPRESSION

DIABETES

DRUG DEPENDENCY

DYSMENORRHEA

EATING DISORDER

FRACTURE

HEART CONDITION

HEPATITIS/LIVER DISEASE

HERPES

HYPERTENSION (HIGH BLOOD PRESSURE)

HYOGLYCEMIA (LOW BLOOD SUGAR)

IRRITABLE BOWEL SYNDROME

MIGRAINE HEADACHES

MONONUCELOSIS

MULTIPLE SCLEROSIS

ORGAN TRANSPLANT

PELVIC INFECTION

PHLEBITIS

RHEUMATIC FEVER

RHEUMATOID ARTHRITIS

SEIZURE DISORDER

SEXUALLY TRANSMITTED DISEASE

STOMACH PROBLEMS/PEPTIC ULCER

THYROID DISORDER

TUBERCULOSIS

URINARY TRACT INFECTION

OTHER:___________________________________________

Give details regarding any condition you marked above:

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

MBU Office of Health Services ! 540-887-7095 ! fax: 540-887-7289 ! dduff@marybaldwin.edu

FAMILY HISTORY Please circle to indicate if the condition exists in your family (parents, siblings, and grandparents):

ASTHMA

BLEEDING/CLOTTING DISORDERS

CANCER

DIABETES

EYE DISORDERS

HEART DISEASE

HIGH BLOOD PRESSURE

MENTAL ILLNESS

RESPIRATORY PROBLEMS

RHEUMATIC FEVER

STROKE

TUBERCULOSIS

OTHER:___________________________________________

ADDITIONAL INFORMATION Answer the following questions:

Allergies: Medications, Foods, Environmental, Seasonal, etc. (Please list):

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Hospitalizations: Yes____ No_____ (if yes, please provide details)

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Surgeries: Yes____ No_____ (if yes, please provide details)

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Medications: Yes____ No_____ (if yes, please list drug name and dosage currently taken)

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

MBU Office of Health Services ! 540-887-7095 ! fax: 540-887-7289 ! dduff@marybaldwin.edu

Do you have a medical condition which may interfere with eating in the university dining hall (special diets cannot be supplied)? No____ Yes_____ (if yes, please specify)

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

MENTAL HEALTH INTERVENTIONS

SPECIAL NEEDS

Have you ever had any treatment or counseling for any emotional, behavioral, or psychological condition?

Yes_____ No_____

Have you ever been treated with any medication for psychiatric reasons? Yes_____ No_____

If the answer to any of the above questions is yes:

• A full report from your physician, psychiatrist, certified therapist, or counselor is required. • The full report will include a statement of the diagnosis, treatment, response to treatment, and need for

follow up. • This report should be directed to the college Health Center, Head Athletic Trainer (if applicable), and

Counseling and Psychological Services. • This report will not be released without the written consent of the student.

Do you consider yourself handicapped or disabled in any way that requires you to receive special consideration from the university? Yes_____ No_____

If so, please give details below:

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

The Health Center works in cooperation with the Office of Student Life in attempting to meet the needs of students with special needs.

Would you object if the Heath Center referred your name to:

Office of Student Life? Yes_____ No_____

Accessibility Services Coordinator? Yes_____ No_____

MBU Office of Health Services ! 540-887-7095 ! fax: 540-887-7289 ! dduff@marybaldwin.edu

Part II: Health Care Provider Evaluation The following information is required from your Health Care Provider for medical clearance into Mary Baldwin University. Please make an appointment with your provider and bring a printed copy of this form for completion and signature.

Student’s Name:_____________________________________________ Date of Birth:___________ Last First Middle MM/DD/YYYY

PHYSICAL EXAMINATION

Area Examined : Normal: Abnormal Findings: (please explain) Lungs/Chest________________________________________________________________________________________

Heart_______________________________________________________________________________________________

Pulses_______________________________________________________________________________________________

SKM________________________________________________________________________________________________

Eyes/Ears/Nose/Mouth/Throat_______________________________________________________________________

Abdomen___________________________________________________________________________________________

Musculoskeletal______________________________________________________________________________________

Neck________________________________________________________________________________________________

Shoulders___________________________________________________________________________________________

Elbows______________________________________________________________________________________________

Wrists/Hands_______________________________________________________________________________________

Back________________________________________________________________________________________________

Knees_______________________________________________________________________________________________

Ankles/Feet_________________________________________________________________________________________

Reflexes_____________________________________________________________________________________________

Other_______________________________________________________________________________________________

Height:___________ Weight:__________ Blood Pressure:________ Pulse:_______

Respirations:__________ Lymph Nodes:_____________

Vision

Corrected (L):__________ (R):____________ (BOTH):___________

Uncorrected (L):________ (R):____________ (BOTH):___________

MBU Office of Health Services ! 540-887-7095 ! fax: 540-887-7289 ! dduff@marybaldwin.edu

IMMUNIZATION RECORD—PUBLIC HEALTH REQUIREMENTS Virginia Code (Sec 23-7.5) requires students attending Mary Baldwin University to provide documentation of their immunizations by a licensed health professional. All information must be documented in the English language.

Student’s Name:_________________________________________ Date of Birth:_______________ Last First Middle MM/DD/YY

REQUIRED

M.M.R. (Measles, Mumps, and Rubella)—Two doses required.

Dose #1 given at age 12-15 months or later Date Given:_______________

Dose #2 given at age 4-6 years or later and at least one month after Dose #1 Date Given:_______________

TETANUS-DIPHTHERIA—Primary series with DtaP or DTP and booster with Td in the last ten years meets requirement—refer to ACIP for details

Primary series of four doses with DtaP or DTP Date series completed:________________

Tetanus-Diptheria (TD) booster within the last ten years Date Given:________________________

POLIO—Primary series in childhood meets requirement, three primary series schedules are acceptable—refer to ACIP for details Date series completed:________________

VARICELLA—History of chicken pox or two doses of vaccine? ( ) No ( ) Yes, given at age____________

Immunization Dose #1 Date:___________________ Dose #2 Date:__________________ (given at least one month after Dose #1 if age 13 years or older)

MENINGOCOCCAL—One dose prior to entry into college (or a booster done at age 16 years or older, first dose given earlier) for students living in residence halls to reduce their risk of contracting meningitis.

Quadrivalent polysaccharide vaccine Date given:____________________________

HEPATITIS B—Three doses of the vaccine are required to complete series.

Dose #1 Date:_________________ Dose #2 Date:______________ Dose #3 Date:__________________

TUBERCULOSIS SCREENING—PPD required regardless of prior BCG inoculation.

PPD (Mantoux) within the past 12 months (tine or monovac not acceptable)

Date Given:_________________ Date Read:______________ Result: Neg______ Pos______

If positive, __________mm induration (horizontal diameter)

If PPD is positive, chest x-ray required. Date:__________________ Results: Normal______ Abnormal______

HIGHLY RECOMMENDED INFLUENZA—Annual immunization in Fall is recommended to avoid disruption to academic activities.

Date vaccinated:__________________

MBU Office of Health Services ! 540-887-7095 ! fax: 540-887-7289 ! dduff@marybaldwin.edu

HEALTH CARE PROVIDER CERTIFICATION

Physician Signature:_______________________________________________________Date:______________

Printed Name:____________________________________________ Phone:____________________

Address:___________________________________________________ Fax:____________________

MBU Office of Health Services ! 540-887-7095 ! fax: 540-887-7289 ! dduff@marybaldwin.edu

ADDITIONAL EVALUATION (FOR ATHLETICS AND VWIL CADETS ONLY)

Participation Status for Athletics/VWIL cadets Physical Training

______Cleared with no restriction

______Not cleared for the following activities:___________________________________________

Due to:_____________________________________________________________________________

Physician Signature:_______________________________________________________Date:______________

Note for athletes: A physical exam and additional forms are required. You may download and print them at marybaldwinathletics.com/information/athletictraining/forms. (This is not required for VWIL cadets.)