For office use only: Jenzabar: / / MM DD YY (Initial) Revision date: 7/10/17 Health Record Health Services 1025 North Broadway, K-254 Milwaukee, Wisconsin 53202 Phone: 414-277-7333 Fax: 414-277-2897 Student Requirement Health Record Form Welcome to MSOE! All students new to the university are required to have this completed Health Record on file with Health Services before the start of your first term at MSOE. Please return this completed Health Record and any attachments to: (By mail): MSOE Health Services 1025 N. Broadway Milwaukee, Wisconsin 53202 Via fax: 414-277-2897 In person: 1245 N. Broadway, Room K-254 Residence Hall students may submit Health Records at the time of their move-in date to Residence Hall staff. An official immunization record is REQUIRED. A. General Information STUDENT ID # Name: Last Name First Name Middle Date of Birth / / International Student Gender: Male Female Other Athlete Major: Resident: Phone: ( ) Residence Hall Room Number Cell or Campus Phone Commuter Address: ( ) Street City State Zip Home Phone Permanent Home Address: ( ) (If different than above) Street City State Zip Home Phone Emergency Contact: ( ) Name Relationship Phone Number Medical Insurance: ( ) Company Policy Number Group Number Phone Number 1
B. Immunizations Note Nursing students only: Once your clinical starts in sophomore year, it will be necessary to submit the original lab report and/or documentation from the health care provider. If you are a nursing student and had the Chicken Pox Disease as a child, you must still verify immunity with a Varicella Antibody Titer. For TB skin test (Section C), it is necessary to have a Two-step TB test before starting your clinical. (Not needed as a freshman.) Measles/Mumps/Rubella (MMR) - (2) doses or positive antibody titer for all 3 diseases; Initial vaccine must be after age 1; at least 28 days between doses) MMR #1 Date: MMR #2 Date: -OR- Provide copies of the original lab reports that verifies immunity. Varicella (Chicken Pox) - (2) vaccines or positive antibody titer Varicella #1 Date: Varicella # 2 Date: Date of disease: -OR- Positive Varicella antibody titer. Provide a copy of the original lab report that verifies immunity. Tetanus/diphtheria/pertussis (Tdap) one dose of Tdap; Tetanus/Diphtheria (Td) every 10 years Tdap Date: Td Date: Hepatitis B: (3) vaccine series; antibody titer can be done 4-8 weeks after dose #3 to confirm immunity Hepatitis B #1 Date: Hepatitis B #2 Date: Hepatitis B #3 Date: + Hepatitis B Surface Antibody titer Date: Provide a copy of all Hepatitis B Surface Antibody titers. Meningitis: (1) vaccine; if given before age 16, need booster Meningitis #1 Date: Meningitis #2 Date: 2
C. Tuberculosis (TB) Risk Questionnaire Yes No Explain Do you currently have a cough? Have you ever had close contact with anyone who was sick with TB? Have you ever had a positive TB test? Are you from a country where TB disease is very common (most countries in Latin America and Caribbean, Africa and Asia (except for Japan) and did you arrive in the US within the past 5 years? Have you ever traveled or lived in a country that has risks for TB? Have you ever been vaccinated with Bacille Calmette-Guerin (BCG)? Have you lived somewhere in the U.S. where TB disease is common (such as homeless shelter or migrant worker camps) Have you ever injected drugs? Please provide the dates and documentation for any of the following Tuberculosis vaccinations or screens. BCG vaccine: Chest X-ray: Quanterferon Gold titer: Date received: Date received: Date received: For TB Only: Date: TB Test Read Date: TB Test Read Results: Positive Negative * Mandatory for all international students to have a TB skin test or a chest X-ray if you received the BCG Vaccine. *If you are not a nursing, perfusion or international student the TB skin test is optional. 3
D. General Health History (Self-reported by student / family) YES NO SYMPTOMS/ DISEASE Allergies Asthma/ Wheezing/ Shortness of Breath Frequent or Sever Headaches Dizziness or Fainting Spells Head Injury/ Concussion/ Passed out Seizures Diabetes Mental Health Concerns Any disability limitations? YES NO SYMPTOMS/ DISEASE Hearing Loss Eye Trouble/ Vision Impairment Heart Trouble Palpation or Pounding Heart Physical Mobility Concerns Back Pain Arthritis, Rheumatoid Arthritis, Bursitis Paralysis (including infantile) Birth Defects If answered yes, please explain in specific details: Any diagnosed medication conditions, mental health concerns or disabilities not previously mentioned: Any medications or supplements taken regularly (Please specify): Any history of hospitalizations? If so, when and what for? 4
E. Student Release of Information (Optional) This is to certify that I (print name) hereby give my consent for the release of any information regarding my health status or information which is on file at the Milwaukee School of Engineering to the following person(s): Name: First Name Last Name Address: Street City State Zip Phone: ( ) Name: First Name Last Name Address: Street City State Zip Phone: ( ) Consent to Release Health Information to MSOE Department I give consent to share this information with the MSOE Athletics Sports Medicine Department. (Optional) I give consent to share this information with Student Accessibility Services at MSOE. (Optional) I give consent to share this information with the MS in Perfusion program directors. (Optional) I attest that the information supplied by me is true and complete to the best of my knowledge. Signature Date MSOE recognizes that due to health or religious reasons, some students may not receive immunizations. If so, please have your physician and/or minister attach a statement addressing these issues to this Health Record. The university reserves the right to require additional health information if data submitted is considered to be inadequate. If you have any questions or need information regarding Health Insurance available through MSOE, please contact: Student Health Services: (414) 277-7333 5
PHYSICAL EXAMINATION (Required for all new MSOE students) Name: Date of Exam: / / Date of Birth: / / Age: Sex: Height: Weight: Blood Pressure: Pulse: Respiration: Any abnormalities of the following systems? Normal Abnormal Neck/Thyroid Teeth/Gums Ears/Nose/Throat Head Respiratory Cardiovascular Gastrointestinal Hernia Eyes Genitourinary Musculoskeletal/Extremities Metabolic/Endocrine Neuropsychiatric Skin Neurological Special Examination Normal Comments/Follow-up/Needs Is there any emergency action needed while at school due to the student s health condition (seizures, asthma, insect sting, bleeding problems, diabetes, heart problems)? Yes No If yes, explain Is the student free from clinically apparent communicable disease? Yes No If no, explain Does the student have any allergies? (Food, drug, insect, other)? Yes No If yes, explain Is the student on any medications, tranquilizers or other psychotropic drugs? Yes No If yes, explain Is the student currently under treatment for any medical or emotional condition that the university needs to be aware of? Yes No If yes, explain and please send signed sheet with current instructions. Is the student cleared to participate in international travel? Yes No If no, explain For nursing or perfusion students: Does the student have the ability to meet the physical demands of the clinical work environment, i.e. lift 50 pounds? Yes No If no, explain Physician/Advanced Practice Nurse/Physician Assistant (MD, DO, APNP, PA) performing examination Print Name: Signature: Address: Phone: ( ) 6