Student Health Information Form

Student Health Information Form Fall Spring Year ______Health form is required to be completed by all students entering Iowa Central Community College as freshman or transferring in from another college. Name: ______SSN# ______Male Female Last First MI

Home Address: ______Street City State Zip

Date of Birth: ______Student Phone Number: ______

Emergency Contact: ______Name Relationship Address

Home/Cell Phone #:______Work Phone #: ______

Family Physician: ______Name Address Phone #

Medical Insurance: (Please enclose a copy of your insurance card) ______Company Policy # I will remain under my current health insurance plan while attending Iowa Central Community College. I currently have no medical insurance. Iowa Central Community College has information for students regarding an insurance plan available for students. Brochures are available in rack outside Health Services office or by calling Health Services at 515-574-1047. Personal Health History Do you have, have you had? Yes No Yes No Yes No Asthma Frequent anxiety Cancer Chicken Pox Chest Pain/Pressure Diabetes Epilepsy/Seizures Frequent Depression Head Injury High/Low Blood Pressure Mumps Headaches (migraines) Heart Disease Kidney Disease Tuberculosis Urinary Tract Problems Mononucleosis Sexually Transmitted Infections Ulcers Frequent Respiratory Illnesses Females: Irregular/Painful Periods Trouble Sleeping Dizziness/Fainting Weakness/Paralysis Please explain all “Yes” responses: ______Is there any other significant health information we need to know about you? ______Medications (Please list any medications taken regularly): ______Allergies (Please list any drug , environmental or other allergies you may have): ______OVER Immunization Information Must be completed by all students born after 1956. Proof of immunizations or immunity is required to attend Iowa Central Community College. It is required that you provide Health Services with a copy of your immunization records obtained from your family doctor or local health department. If Health Services does not receive a copy of your health information form & your immunization records, you will not be allowed to register for next semester classes.

**Health Science students must follow the requirements of immunizations for the Health Science department. Please check with them upon admission.

REQURED IMMUNIZATIONS OF ALL NEW STUDENTS (Including transfer students)  Measles (Rubeola) Immunity: (Please check one of the following options) 1. I have had two doses of live measles vaccine (MMR). Two doses are required for admission. (See Record) First Dose must be on or after 1st birthday. Second Dose must be given in 1980 or later and at least 30 days after the first. I have had Measles (Rubeola) disease. ______Year 2. I am exempt because I was born before January 1, 1957.  Tuberculosis (TB) Testing is required for all Non-U.S. Citizens after arriving in the United States or for anyone who has traveled outside the United States in the past 12 months. Date administered ______By ______Site ______Date read ______By ______Results ______This test is available through the Health Services Offices if needed for a fee.  Meningitis: (Please check one of the following options) 1. I have been vaccinated (See Record). 2. I have not been vaccinated. I have been informed and have reviewed the Vaccine Information Statement provided about the Meningococcal Disease and the Meningococcal Vaccine and am refusing to be vaccinated at this time. By signing this I am showing that I have been informed of the Meningococcal Disease and have not been vaccinated and I am refusing the vaccination at this time. ______Signature Date

RECOMMENDED IMMUNIZATIONS  Hepatitis B – Hepatitis B vaccine is to protect against Hepatitis B which is transmitted via blood or body fluids by sexual contact, exposure to blood or body fluid, sharing of needles, etc. This is a 3-shot series.  Varicella- Varicella vaccine protects against the chicken pox virus. Either a history of chicken pox or two doses of vaccine given at least one month apart if immunized after age 13 years meets the recommendation.  Tetanus – It is required for children to have the tetanus series for elementary school enrollment. It is recommended students receive a booster shot upon entrance into college. This series would fulfill the recommendation for college. Normally tetanus is a 4-5 shot series plus boosters every 10 years.  Polio - It is required for children to have the polio series for elementary school enrollment. That series would fulfill the recommendation for college. Normally polio is a 3-4 shot series.

Emergency Treatment Consent: In case of an accident or an emergency in which I may be unable to direct my own medical care, I authorize Iowa Central Community College to seek appropriate medical/surgical care for me until those identified as emergency contact persons can be notified. I hereby state that the above information is true and give permission for Health Services to release information to any Iowa Central Community College staff including administration, athletic trainers, campus counselor, housing staff, and/or teaching staff, and to health care providers or facilities who are included in my treatment. If under 18, must be signed by both student and parent/guardian.

Student’s Signature ______Date ______

Parent/Guardian Signature ______Date ______