Greetings, On behalf of Health Services, congratulations and welcome to Nichols College! We look forward to you becoming part of our campus community! Please see the attached packet of Health Record requirements, and carefully review the checklist provided. A physical exam by your Primary Care Physician is mandated within the 2020 calendar year, if you received a physical in 2019 check with your insurance provider as most companies allow a physical once every calendar year starting January 1st. Please note that doctors' offices are extremely busy, and it may be difficult to schedule an appointment on short notice. We highly recommend that you call your doctor as soon as possible to schedule your physical exam if you haven't already done so, and remember to have as much information on the form filled in as possible. NON-ATHLETES: If you have any questions or medical concerns, please contact Health Services at 508-213-2238. Please note that Health Services office hours are minimal during the summer, but messages are checked frequently and someone will get back to you as soon as possible. If you need immediate assistance, please contact Student Services at 508-213-2480. Non-athletes must mail back their completed health forms by Friday, August 7th, or bring them to the nurse's station on move-in day. ATHLETES: If you will be participating in intercollegiate sports, NCAA regulations mandate that you have a physical within 6 months of arriving on campus. If you have any questions, please contact Tim Bennett, Head Athletic Trainer, at 508-213-2183. Athletes must mail back their completed health forms by Monday, August 3rd. If you do not have confirmation that the Health Center or Sports Medicine has received your packet, please make copies of your forms and bring them to your team’s check-in to guarantee participation clearance. Incomer’s Checklist Sincerely, - Print out this entire packet Katherine Nicoletti RN - Complete Health Record and Student Health History forms Director of Health Services and College Nurse Health Services - Have your Physician complete the Physical and Phone: 508-213-2238 Immunization forms Fax: 508-213-2134 - Make a copy of your current Insurance card (Front [email protected] & Back) - Copy all completed forms (One for Health Center Timothy R. Bennett MBA ATC/L and one for Athletics) Head Athletic Trainer - Send all copies to Nichols College in envelope. Athletics Health Care Administrator (121 Center Rd, Dudley, MA 01571-5000) Department of Athletics Phone: 508 213-2183 *If you are an Athlete* Fax: 508-213-2446 Complete attached AT Waiver and Sickle Cell [email protected] Waiver forms. (pgs. 10-12) Make sure Physical date is within 6 months from Nichols College arriving on campus. (Required by NCAA) Learn. Lead. Succeed. 1 FOR OFFICE USE ONLY HEALTH RECORD MAIL COMPLETED RECORD TO: Office of Health Services Nichols College P.O. BOX 5000 Dudley, MA 01571 NAME: DATE OF BIRTH: (LAST) (FIRST) (MIDDLE INITIAL) CELL PHONE #: ( ) HOME PHONE#: ( ) STUDENT ID#: HOME ADDRESS: (STREET) (CITY) (STATE) (ZIP) EMERGENCY CONTACT INFORMATION PARENT/GUARDIAN: PARENT/GUARDIAN: RELATIONSHIP: RELATIONSHIP: ADDRESS: ADDRESS: EMERGENCY PHONE: EMERGENCY PHONE: INSURANCE INFORMATION (All students are required by Sate Law to have Health Insurance. Insurance must be current and valid.) *PLEASE PROVIDE A COPY OF YOUR INSURANCE CARD FRONT AND BACK. INCLUDE SECONDARY INSURANCE AND PRESCRIPTION INFORMATION* NAME OF INSURANCE COMPANY: PHONE #: POLICY #: GROUP #: SUBSCRIBER: SUBSCRIBER DOB: EMPLOYER: PLEASE CIRCLE ALL THAT APPLY: RESIDENT COMMUTER FRESHMAN TRANSFER RE-ADMIT (If applicable, please list the dates you were a previous student at Nichols__________________) PREVIOUS COLLEGE: (If applicable, please list the dates enrolled at previous college__________________) PLEASE INDICATE IF YOU WILL BE PARTICIPATING IN AN INTERCOLLEGIATE SPORT: YES NO UNSURE WHAT SPORT(S) WILL YOU BE PARTICIPATING IN? (LIST) CONSENT FOR TREATMENT I, the above named student give informed consent for the routine care through the Nichols College Office of Health Services, Mental Health Services and if an Athlete the Nichols College Athletic Department and in the event of an EMERGENCY, give permission to the above named departments and its affiliated hospital to secure for this student appropriate treatment, including orders for surgery and anesthesia if necessary. Your signature also allows Health Services, Mental Health Services and if an athlete the Athletic Department to release any PERTINENT medical and mental health information (i.e., allergies, immunization status, special medical conditions or mental health concerns) to Student Services, Advising Services, Res. Life, Academic Services and Public Safety. These entities will be allowed to share information as determined appropriate to assure the safety and well-being of the student. STUDENT SIGNATURE X___________________________________________________________________________ PARENT OR GUARDIAN SIGNATURE X_______________________________________________________________ (Required if student is 18 or under) Nichols College 2 Learn. Lead. Succeed STUDENT HEALTH HISTORY FORM Please complete this form before going to your Physician for examination. NAME: DATE OF BIRTH: (LAST) (FIRST) (M.I) PERSONAL HISTORY: Have you ever had or have now? (PLEASE CHECK ALL THAT APPLY) Anemia Depression HIV Infection/Disease Pneumothorax Anxiety Diabetes Kidney Stones/Disease Seizure Disorder Anorexia/Bulimia Dizziness/Fainting Spells Learning Disabilities Sickle Cell Anemia Arthritis Emotional/Mental Health Illness Meningitis Bacterial/Viral STD’s Asthma Frequent Ear Infections Menstrual Problems Substance Abuse Problems Bronchitis Heart Disease/Problems/Murmurs Migraines/Chronic Headaches Thyroid Disease Back Problems Hepatitis (Type: ) Mononucleosis TB/Tuberculosis Cancer Head Injury/Concussion Neuromuscular Disease Ulcer/Stomach Problems Chicken Pox High Blood Pressure Nose Bleeds UTI’s Frequent/Recurrent Crohn’s/Colitis/BS High Cholesterol Phlebitis/Deep Vein Blood Clot Vision/Hearing Problems OTHER: Please Explain Checked Answers: ARE YOU CURRENTLY UNDER A PHYSICIAN’S CARE? IF YES PLEASE EXPLAIN. ARE YOU CURRENTLY, OR PREVIOUSLY BEEN, IN COUNSELING? IF YES PLEASE EXPLAIN. ARE YOU CURRENTLY TAKING MEDICATIONS? IF YES PLEASE LIST MEDICATIONS AND LIST PRESCRIBER(S). ANY PRIOR HOSPITALIZATIONS? IF YES PLEASE LIST DATES, DIAGNOSIS, AND SURGERIES. ANY OTHER PRIOR ORTHOPAEDIC INJURIES? ANY ALLERGIES? IF YES PLEASE LIST. DO YOU HAVE AN EPI PEN? YES / NO IF YOU HAVE ASTHMA DO YOU HAVE AN INHALER? YES / NO IF AVAILABLE, WHAT IS YOUR BEST PEAK FLOW? FAMILY HISTORY LIFESTYLE Has anyone in your immediate family 1. Alcohol (Drinks/day)? ____________________________________________ Yes No Relationship had any of the following? 2. Cigarettes/Vape per day? ____________ Years Smoked/Vaped? __________ 3. Do you diet frequently? __________________________________________ Alcoholism Asthma 4. Do you exercise regularly (days/week)? _____________________________ 5. Do you or have you ever used recreational drugs? Bleeding Disorders Yes / No What type? ___________________________ Epilepsy/Seizures 6. Do you or have you ever used prescription medications for recreational use? Emotional Disorders Yes / No What type? ___________________________ Heart Attack Heart Disease High Blood Pressure ALL INFORMATION PROVIDED IS CONFIDENTIAL Kidney Disease Stroke Breast Cancer PROGRAMS INTERESTED IN ATTENDING Other Cancer 1. Exercise Classes (Circle all that apply) Other Yoga / Pilates / Step Classes / Muscle Mix / Kickboxing / Other_______ Depression/Anxiety/Panic Disorder 2. Stop smoking program? Yes / No 6. Nutrition Class? Yes / No Other 3. Substance abuse program? Yes / No 7. Heart Health Class? Yes / No I have answered these questions to the best of my knowledge. 4. Stress reduction classes? Yes / No 8. Anger management? Yes / No 5. Weight loss program? Yes / No 9. Other ____________________ STUDENT SIGNATURE X__________________________ Nichols College 3 Learn. Lead. Succeed PHYSICIAN PHYSICAL EXAM FORM Physician, please review the Student Health History and complete Physician Form, no attachments accepted. A physical exam within the calendar year is required. *FOR ATHLETIC, CLUB SPORT OR INTRAMURAL IT IS MANDATORY.* STUDENT NAME: DATE OF BIRTH: T P R AGE SEX M F WEIGHT HEIGHT BMI B/P / U/A S.G. PH PROTEIN SUGAR OTHER Hgb/Hct Cholesterol MEDICAL EXAM NORMAL ABNORMAL MEDICAL EXAM NORMAL ABNORMAL COMMENT ON ABNORMAL FINDINGS Appearance Abd, Liver, Spleen, Kidneys Skin G-U System Eyes (lids, conjunctiva, pupils) Rectal Ears (canals, drums) Hernia Vascular (femoral, pedal pulses, Nose, Sinuses, Throat varicosities) Mouth, Teeth, Gingiva Lymph Nodes Neurological (gait, patellar, Neck, Thyroid Achilles reflexes, balance) Musculoskeletal (back, spine, Chest, Breasts joints, shoulders, knees, ankles) Lungs Heart NO YES CARDIAC SCREENING COMMENT ON YES ITEMS PHYSICAL EXAM Chest pain with exercise Normal Abnormal Precordial Auscultation Fainting or dizziness with exercise Supine Heart races or skips beat with exercise Squatting Hypertension Standing Standing with Valsalva Family hx of sudden death before age 50 Femoral artery pulses Family hx heart disease before age 50 COMMENT ON ABNORMAL ITEMS Dilated cardiomyopathy Long Q-T syndrome Marfan’s Syndrome Clinically important arrhythmias Heart murmur PHYSICAL STIGMATA FOR MARFAN SYNDROME YES NO *CLEARED TO PARTICIPATE IN INTERCOLLEGIATE SPORTS?* YES NO PLEASE INDICATE RESTRICTIONS HERE