STUDENT HEALTH CERTIFICATION

Hubbs Health Center 119 St. Clair Street

Geneva, NY 14456

STUDENT HEALTH CERTIFICATION

315-781-3600 Fax 315-781-3802

Name___________________________________________________________________________________________________________

Home Address ____________________________________________________________________________________________________ Street City State Zip Code Home Phone ____________________________ Student’s Cell Phone ______________________________

Date of Birth ____________________________ Gender: Male/Female (circle one)

Parent/Guardian ______________________________________ Relationship _________________ Phone _______________________ Parent/Guardian ______________________________________ Relationship _________________ Phone _______________________ Address ________________________________________________________________________________________________________

Street City State Zip Code

Health Insurance Information

IT IS MANDATORY FOR ALL HWS STUDENTS TO BE ENROLLED IN A HEALTH INSURANCE PLAN THAT COVERS SERVICES WHILE AT COLLEGE. THE STUDENT WILL BE REQUIRED TO PRESENT HIS/HER HEALTH INSURANCE CARD AT HUBBS HEALTH CENTER AT EACH VISIT. IF THE STUDENT HAS NO CARD, THERE MAY BE A DELAY IN ALL MEDICAL SERVICES OUTSIDE OF THE HEALTH CENTER.

Name of Insurance Company ________________________________________________________________________________________ Insurance Company Address ________________________________________________________________________________________

Street City State Zip Code

Insurance Company Phone ________________________________

Policy Holder’s Name _________________________________________________ Policy Holder’s Date Of Birth ___________________ Policy Number ___________________________________________________ Group Number __________________________________ Is Student fully covered while living in Geneva? Y N Is there need for prior approval by primary care physician? Y N Does the student have dental insurance? Y N Does the Insurance cover student if traveling abroad? Y N

INSTRUCTIONS AND INFORMATION – IMPORTANT - PLEASE READ!

The Personal Medical History, and the Meningitis Response section, page 4, must be completed by the student. The Immunization and Physical Examination forms must be completed by your Health Care Provider.

Full clearance for registration will not be granted until all pre-entrance medical requirements have been completed.

This Student Health Certification form must be completed and returned no later than July 10, 2015 in order to register for classes.

PERSONAL MEDICAL HISTORY (to be filled out by student)

Have you ever had or now have any of the following? (check each item yes or no

)

Have You Had? Yes No Have You Had? Yes No Have You Had? Yes No

Allergies Rheumatic Fever Gallbladder disorder

Medication Allergies Pneumonia Chicken Pox

Eye problems Asthma Mononucleosis

Ear, nose throat problems Chronic Cough Hernia

Sinusitis TB/Positive TB test Genital disorder

Hearing impairment Skin disease Irregular menstruations

Fainting Spells Recurrent Urinary Infection Athletic Injury

Migraines Kidney problems Operations

Concussion Irritable Bowel syndrome Eating Disorder

Meningitis Chronic intestinal problem Cancer

Epilepsy, seizure disorder Diabetes Thyroid trouble or goiter

Heart disease Hepatitis Anemia

Sickle cell Trait Other

Explain any yes answers from above: __________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ Please list any allergies (medications, food, bee stings, etc.): ______________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ Are you currently taking any prescribed or over the counter medications, herbal medications, or dietary supplements? (please include vitamins, contraceptives, etc.) Yes ___ No ___ If yes, list medication, dosage and frequency. ________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ Have you ever been hospitalized for any surgical, medical or psychiatric illness? Yes ___ No___

If yes, please explain. ______________________________________________________________________________________________ ________________________________________________________________________________________________________________ Are you happy with your present weight? Yes____ No____ If no, why?____________________________________________________ Do you smoke? Yes ____ No____ If yes, amount (per day) _____________________________________________________________ Do you drink alcohol? Yes ____ No_____ If yes, Daily________ Weekly ________ Occasionally________

Do you use any illicit of drugs? Yes____ No____ If yes, what type __________________________________ Daily ________ Weekly ________ Occasionally ________

Physical examination is required within 1 year of admission. The physical and immunization form is to be filled out by the examining health care provider. Please review student’s history prior to completing the form below.

Prospective athletes are advised to discuss with their home physician the advisability of pre-participation echocardiogram and graded exercise test in order to screen for rare congenital heart ailments, which have been associated with sudden death on the playing field.

Name ___________________________________________ DOB _________________ Date of Exam ____________________

Last First mm/dd/yyyy mm/dd/yyyy

Height __________ (inches) Weight __________ (lbs.) BMI __________ Blood Pressure _____/_____ Pulse __________ Vision: with correction lenses Yes____ No____ OD __________ OS __________

Check each item in the proper column. (NE if not evaluated) List any abnormal findings below.

Normal Abnormal Normal Abnormal

Head, face and scalp Abdomen

Eyes Hernia

Ophthalmoscopic Anus and rectum

Nose G-U system

Ears and hearing Upper extremities

Mouth, teeth and gingiva Lower extremities

Throat Musculoskeletal and Spine

Neck Skin/lymphatic

Thyroid Neurologic

Chest and lungs Pelvic exam

Breasts Testicular exam

Heart HIV testing

Vascular System

Please explain any abnormal findings: ________________________________________________________________________________ _______________________________________________________________________________________________________________ Will treatment for chronic ailment be required? If so please list with required medication.

_______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ At present, do you believe the student will need, or would desire to consult a psychiatrist, psychologist or a member of the medical staff while at college? If so explain. _______________________________________________________________________________________ I have examined this patient. I find him/her eligible to participate in all intercollegiate athletic sports. I understand this includes but is not limited to football, soccer, ice hockey, field hockey, basketball, cross country, swimming, crew, sailing, squash, golf and tennis. The following restrictions regarding the patient’s activity include: _____________________________________________________________ ________________________________________________________________________________________________________________ Health Care Provider’s name___________________________________________________________________________ (please print) Health Care Provider’s Signature _____________________________________________________________ Date__________________

Immunization Record:

Enter info mm/dd/yyyy format in English. You may attach a copy of the immunization record.

Name _______________________________________________________________________ DOB _________________________

Last First mm/dd/yyyy

NEW YORK STATE PUBLIC HEALTH LAW 2165 requires post-secondary students to show protection against measles, mumps and rubella. Two measles immunizations are required, and may be administered no more than four days prior to the first birthday, and a second dose of the vaccine administered no less than 28 days after the first dose.

In the event of an outbreak, exempted person will be subject to exclusion from school. M.M.R. (Measles, Mumps, Rubella) (Two doses required or positive serology)

Dose 1 given at age 12-15 months or later ___/___/___ Dose 2 given at least 28 days after first dose ___/___/___ Serology (include lab report) M ____________ M____________ R ____________

NEW YORK STATE LAW 2167 requires one of the following options be completed and signed by student or by parent/guardian of the student under the age of 18.

Menomune Menactra Menveo ____/____/____ (date given) (one dose within 10 years)

I have obtained and read the information regarding meningococcal meningitis disease. I (my child) will obtain immunization against the disease within 30 days of the beginning of the semester.

I have obtained and read the information regarding meningococcal meningitis disease. I understand the risks of not receiving the vaccine. I have decided that I (my child) will not obtain immunization against the disease.

Signature ____________________________________________________________ Date _______________

TUBERCULOSIS RISK ASSESSMENT: Please check one ____LOW RISK ____HIGH RISK (SEE BELOW)

If a student is high risk for exposure, documentation of a Tuberculin Skin Test (Mantoux ) or a Quantiferon blood test is required WITHIN SIX (6) MONTHS prior to arrival at Hobart and William Smith Colleges. This includes ALL INTERNATIONAL STUDENTS FROM AFRICA, ASIA, LATIN AMERICA and EASTERN EUROPE. High risk is additionally defined as prior contact with a person with TB, having traveled to any of the above named regions in the last 5 years, having lived or worked in a nursing home, prison, mental institution, homeless or HIV setting or having a compromised immune system function (history of HIV infection, immune suppressing medication, chemotherapy, chronic renal failure, diabetes , injection drug use etc.)

Mantoux (PPD) placed: ___/___/___ Read: ___/___/___ Results_____________mm. induration

If >10mm induration, chest x-ray is required. Date:___/___/___ Results____________________________________________ Quantiferon IGRA Date :___/___/___ (please specify) ____ QFT-G ____QFT-GIT ____T-SPOT Result : ___ NEG ___POS If positive, chest x-ray is required Date of chest x-ray: ___/___/___/ Results ________________ _______________________________ Note any prophylactic treatment provided with the date initiated _____________________________________________________________

Other Vaccines

Vaccine Guidelines Dates Administered

Tetanus-Diphtheria-Pertussis

Primary series with booster in last 10 years REQUIRED

1. ___/___/___ 2.___/___/___ 3.___/___/___ 4.___/___/___ Booster: TD ___/___/___ TDAP ___/___/___

Polio Primary series

REQUIRED Date series completed ___/___/___ Booster ___/___/___ ___/___/___ Varicella If no documented history _{of disease, two doses} 1.___/___/___ 2.___/___/___ History of disease ___/___/___ _{or Documentation of Positive Titer ___/___/___} Hep A Recommended two dose _series 1.___/___/___ 2. ___/___/___

Hep B Recommended three

dose series 1.___/___/___ 2.___/___/___ 3.___/___/___ HPV Recommended three dose series 1.___/___/___ 2.___/___/___ 3.___/___/___ Pneumococcal Polysaccharide

One dose for high risk

groups 1.___/___/___

Health Care Provider’s name___________________________________________________________________________ (please print) Health Care Provider’s Signature _____________________________________________________________ Date__________________ Address _______________________________________________________ Phone ____________________ Fax __________________

March 2015

Dear Parent and Student,

As Medical Coordinator of Hubbs Health Center and on behalf of the medical staff at the Health

Center please accept my welcome. I am writing to inform you about meningococcal disease, a

potentially fatal bacterial infection commonly referred to as meningitis, and the New York State Law

to which it pertains. On July 22, 2003, Governor Pataki signed New York State Public Health Law

(NYS PHL) §2167, requiring colleges and universities to distribute information about meningococcal

disease and vaccination to all enrolled students whether they live on or off campus. This law became

effective in August 2003.

Hobart and William Smith Colleges are required to maintain a record of the following for

each student:

• A response to receipt of meningococcal disease and vaccine information signed by the student or

student’s parent or guardian. This information must include the availability and cost of

meningococcal meningitis vaccine (Menomune™, Menactra™ or Menveo ™) AND EITHER

• A record of meningococcal meningitis immunization within the past 10 years; OR

• An acknowledgement of meningococcal disease risks and refusal of meningococcal meningitis

immunization signed by the student. If the student is a minor (under the age of 18) the parent or

guardian must sign the waiver.

Meningitis is rare. However, when it strikes, its flu-like symptoms make diagnosis difficult. If not

treated early, meningitis can lead to swelling of the fluid surrounding the brain and spinal column

as well as severe and permanent disabilities, such as hearing loss, brain damage, seizures, limb

amputation, and even death.

Cases of meningitis among teens and young adults 15 to 24 years of age (the age of most college

students) have more than doubled since 1991. The disease strikes as many as 3,000 Americans

each year and is responsible for 150-300 deaths. Between 100 and 125 meningitis cases occur on

college campuses per year and as many as 15 students will die from the disease.

Geneva, New York 14456 | P (315) 781-3600 www.hws.edu

MENINGITIS DISEASE AND IMMUNIZATION INFORMATION LETTER, cont.

Four vaccines are available in the United States:

• Meningococcal polysaccharide vaccine (MPSV4, also known as Menomune)

• Meningococcal polysaccharide diptheria toxoid conjugate vaccine (MCV4, also known

as Menactra)

• Meningococcal oligosaccharide diphtheria CRM 197conjugate vaccine (also known as

Menveo)

• Serogroup B Meningococcal Disease Vaccine

The first three listed above can protect against four types of the bacteria that cause meningitis in

the United States. A,C.Y,W-135. These types account for approximately three-quarters of the

meningitis cases among college students. serogroup B meningococcal disease vaccine, the newest

one protects against serogroup B meningitis.

As many have already learned through various news sources, on February 26, 2015, the U.S. Centers

for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices (ACIP)

voted to recommend serogroup B meningococcal vaccination for persons aged 10 years and older at

increased risk for meningococcal disease, including:

•

Persons with persistent complement component deficiencies.

Persons with anatomic or functional asplenia.

•

Microbiologists routinely exposed to isolates of Neisseria meningitidis.

•

Persons identified to be at increased risk because of a serogroup B meningococcal disease

outbreak.

At this time there is not a general recommendation concerning routine use of the serogroup B

meningococcal vaccination. No action on the HWS health form, page 4, under New York State Law

2167, needs to be taken in regards to serogroup B vaccine.

Hobart and William Smith Colleges offer Menactra™ to any student who requests it. The cost of the

vaccine will be approximately $125 and must be prepaid to the Hubbs Health Center by the student

or his/her parents. Health insurance reimbursements for this vary. If requested, Hubbs Health Center

will provide you with a copy of the immunization charge to be submitted by you to your insurance

carrier for reimbursement.

I encourage you to carefully review the enclosed materials. Please indicate your choice of

vaccine or waiver on the pre-admission physical exam form within the immunization section.

NOTE: PER PUBLIC HEALTH LAW, NO INSTITUTION SHOULD PERMIT ANY STUDENT

TO ATTEND THE INSTITUTION IN EXCESS OF 30 DAYS WITHOUT COMPLYING WITH

THIS LAW. THE 30-DAY PERIOD MAY BE EXTENDED TO 60 DAYS IF A STUDENT CAN

SHOW A GOOD FAITH EFFORT TO COMPLY.

To learn more about meningitis and the vaccine, please feel free to contact our health service

and/or consult your child’s physician. You can also find information about the disease at the

Colleges’ Web site at www.hws.edu, New York State Department of Health Web site:

www.health.state.ny.us, website for The Centers For Disease Control And Prevention (CDC):

www.cdc.gov/ncidod/dbmd/diseaseinfo, and the American College Health Association’s Web

site: www.acha.org

Sincerely,

Betti Green, R.N.A.N.P-BC

Betti Green, R.N.A.N.P-BC

Clinical Coordinator Hubbs Health Center Hobart and William Smith Colleges

AUTHORIZATION AND CONSENT FOR THE MEDICAL TREATMENT OF A MINOR Hobart and William Smith Colleges

(T H I S FORM I S MAN DAT ORY FOR AN Y PAREN T WH OSE CH I LD I S N OT 18 YEARS OF AGE OR OLDER)

Students under the age of 18 are considered minors under the laws of New York State. Therefore, if your child needs specific medical treatment, including the administration of medication while at the Colleges, appropriate consent is required before the treatment can be provided. To protect the interests of your child, as well as the interests of the Colleges, we ask that the parent(s) or legal guardian(s) of every minor student sign this A uthorization form prior to enrollment.

A s the parent(s) or legal guardian(s) of __________________________________________________________ [name of Minor], _______________ [Birthdate], I/We give permission for the appropriate licensed health care provider of the Student Health Center to proceed with the following specifically prescribed administration of medication and/or treatment (‘‘Treatment’’) for my/our child:

Prescribed Treatment: _______________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Duration of Treatment: ______________________________________________________________________ Identified A llergies or Special Medical/Other Conditions: ___________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ This Treatment has been prescribed by my/our child’s licensed health care practitioner, as reflected in the attached documentation. The licensed health care practitioner must countersign this A uthorization to confirm that the description of the Treatment is accurate and complete.

A dditionally, in the event that my child requires unexpected medical, dental, and surgical care (including, but not limited to, first aid, over-the-counter and/or emergency medications, health counseling, diagnostic procedures, and surgical treatments), and/or hospitalization while at the Colleges during any period of my/our absence, I/We, being the parent(s) or guardian(s) of the above named minor, do hereby appoint the authorized medical staff of the Student Health Center and/or the appropriate Dean of the College (Hobart or William Smith) to consent to and authorize such appropriate and necessary care and treatment on my/our behalf.

This A uthorization shall be presented to a physician, dentist, hospital representative, or other appropriate health care practitioner at such time as unexpected medical, dental, and surgical care, and/or hospitalization may be required.

The appropriate licensed health care providers of the Colleges are authorized to obtain medical records information from my/our child’s health care practitioners in order to provide the Treatment and for all of the other health care treatment purposes noted in this A uthorization. It is acknowledged that the disclosure of such

health information to the Colleges is for treatment purposes, and thus does not require further written authorization under the federal Health Insurance Portability and A ccountability A ct of 1996 (‘‘HIPA A ’’).

AU T H ORI ZAT I ON AN D CON SEN T FOR T H E MEDI CAL T REAT MEN T OF A MI N OR (CON T ’D) This A uthorization will remain valid until my/our child reaches eighteen (18) years of age, or until revoked or changed.

I/We understand that this A uthorization may be revoked at any time, provided that I/We submit a signed revocation letter to the Colleges. However, any revocation shall not apply to the extent that the Colleges have taken action in reliance on this signed A uthorization.

I/We understand that I/We are obligated to immediately inform the Colleges of any changes to our child’s Treatment and specific medical treatment needs, including the administration of medication while at the

Colleges, and I/We acknowledge that the Colleges will rely upon the receipt of such information on a timely basis. Parent/Guardian: Signature: _____________________________________________________ Date: ____________________ A ddress: __________________________________________________________________________________ Signature: _____________________________________________________ Date: ____________________ A ddress: __________________________________________________________________________________ Witness: Signature: _____________________________________________________ Date: ____________________ A ddress: __________________________________________________________________________________ Signature: _____________________________________________________ Date: ____________________ A ddress: __________________________________________________________________________________ H ealth Care Practitioner (s):

Name: ______________________________________________________ Phone: ______________________ Name: ______________________________________________________ Phone: ______________________