Returning Student Health Form

Personal Information

Name

First Last

Gender

Male

Female

Social Security Number

Student cell-phone number

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Country of Citizenship

Country of Birth

Insurance Company

Insurance Policy Number

Emergency Contact

Person to notify in an emergency

Relationship to student

Phone

Email

Physician's name

First Last

Physician's phone number

Physician's address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Tuberculosis Test

TB skin test date administered

Date TB skin test read

TB skin test result

Positive

Negative

Chest x-ray (required if skin test is positive) date read

Result

Positive

Negative

Immunization Records

Meningococcal vaccine: RECOMMENDED if living in campus housing

MPSV

MCV4

Date administered

Hepatitis B: REQUIRED for all students born after 1988. Dose #1 date

Dose #2 date

Dose #3 date

Varivax (chickenpox vaccine): Two doses REQUIRED if vaccinated. Dose #1 date

Dose #2 date

Dose #3 date

Tetanus Diphtheria date administered (if more than 10 years ago, student is strongly encouraged to receive a booster)

Measles, Mumps, and Rubella (German Measles): Suggested for all students born on or after January 1, 1957; two doses are recommended, one dose is considered unreliable. Dose #1 date

Dose #2 date

OR Disease date

Validated by (give name and title, MD, RN, LVN, or PA)

Attach copies of immunization records

Max. file size: 512 MB.

List all prescription medications taken on a regular basis

Name of medication

Dosage

How often taken

Reason for taking

Name of medication

Dosage

How often taken

Reason for taking

Name of medication

Dosage

How often taken

Reason for taking

Section Break

Name of medication

Dosage

How often taken

Reason for taking

Attach additional documents if necessary

Max. file size: 512 MB.

I, the undersigned, certify that the information I have provided is truthful, accurate, and complete to the best of my knowledge. I understand that the University may require a student to seek medical or mental health diagnosis, car, and/or treatment in the case of emergency, infectious disease, and/or harm or threat to others. In case of medical emergency, where I am unable to give permission for treatment, I authorize Hannibal-LaGrange University staff to take whatever steps may be necessary to address my medical emergency. i also grant permission for Hannibal-LaGrange staff to contact my parent, guardian, or designee, and my physician. If a life-threatening emergency exists, staff may do any or all the following: (a) Call another physician or the paramedics, (b) call an ambulance, or (c)take me to an emergency medical unit. The college will not be responsible for anything that may happen as a result of false medical or personal information given at the time of school enrollment or during the medical emergency. Any expenses incurred will be borne by the student and/or legal guardian.

I have read this entire release and verify its accuracy. I agree to hold harmless, and release and discharge Hannibal-LaGrange University, its employees, and agents from all claims and demands resulting from an emergency situation.(Required)

Yes

Signature(Required)

I am 18 or will be on or by August 1(Required)

Yes

No

HLGU Returning Student Health Form

Personal Information

Emergency Contact

Tuberculosis Test

Immunization Records

Student Medical History

List all prescription medications taken on a regular basis

Section Break