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Washington Adventist University - Gateway to Service - adventist healthcare washington adventist hospital

WASHINGTON ADVENTIST UNIVERSITY HEALTH SERVICE PRE-ENTRANCE REQUIREMENTS AND HEALTH SERVICE DOCUMENTSHealth Services endeavors to accommodate any health care needs you may have during your stay at Washington Adventist University. The required documentation contained on the following pages serves a twofold purpose: To comply with federal and state recommendationsTo promote good health for our students All students enrolled for six or more credit hours must submit these documents before the beginning of the first semester of attendance at WAU. Submit completed forms to Student Life Office, Wilkinson Hall, First floor, or through intercampus mail. You can also mail or fax completed forms. Address and fax numbers are listed on the Medical History form. PRE-ENTRANCE HEALTH REQUIREMENTS The following documents must be submitted before registration.Medical History. This is to be filled out by the student. Answer all questions fully on this enclosed form.Physical Examination. This is to be performed by the physician (or other authorized health care provider). This exam must have been done within the previous 12 months. It is strongly preferred that the enclosed form be submitted. If another form is used, it should contain all of the same information that is on this form. Immunization Record. This record should show the dates the student received the listed vaccines and must be signed and dated by the appropriate health care provider. See the enclosed form for additional instructions. If you cannot locate part or all of your records, free or low cost resources may be available to you. Contact Office of Student Life for this information. Authorization to Treat Minors. This form must be completed for all students under the age of 18. The Authorization Form is enclosed and located under the Immunization Record. Accident Insurance. This insurance is provided by WAU for all traditional students registered for six or more credit hours. It is the responsibility of the student to process any claims, and forms are available in the Student Life office. Foreign Student Sickness Insurance. International students on an F-1 visa are required to have sickness insurance coverage. This can be obtained as outlined above. Another policy can be substituted if valid proof of coverage is presented to the Office of Student Life. Additionally, an Insurance Waiver must be submitted yearly.Student LifePhone: 301-891-45257600 Flower AvenueFax: 301-891-4155Takoma Park, MD 20912Wilkinson Hall, First Floorwww.wau.edu Washington Adventist UniversityPre-Entrance Health Requirements Please type or print legibly and answer completely. Physical exams and lab work must have been done within the previous 12 months. Attach any required supporting documents as needed. All information is confidential, not to be released without permission. Date: _________________ Sex: Male / Female Class: Fr, So, Jr, Sr. Major: ________________________Name: ______________________________________ Birth Date: ________Age: ___ ID/SS#: ________________ Last, First, Middle I.Emergency Notification: ________________________________________________________________________NamePhone NumberSchool Address: _______________________________________Phone Number: __________________________Home Address: ______________________________________________Home Number: ____________________Marital Status (circle): Single Married Divorced/Widowed Religious Preference: _____________________MEDICAL HISTORY(To Be completed by student) Allergies: _______________________ Medicines: ________________________ Foods: ________________________Other: __________________________________________________________________________________________List and date past major surgeries: ____________________________________________________________________Hospitalizations: _________________________________________________________________________________Serious Illness/Accidents: __________________________________________________________________________Contagious Diseases: ______________________________________________________________________________Currently under medical care (yes/no) for _________________Current medicines: _____________________________Special diets/other: ________________________________________________________________________________Please indicate which of your blood relatives have/have had:High Blood pressure: __________Stroke: __________ Diabetes: __________ Mental Ill: ____________Heart Disease: ________________Cancer: __________ Ulcers: ____________ Other: ________________Please indicate the year you have had any of the following.Ears, Nose, Throat Freq,Vomiting _________ Fainting spells ___________ Hearing difficulties ________ Freq.Indigestion _________ Muscular/Skeletal Sinus infections ________ Ulcers _________ Severe back pain ___________ Freq. sore throats/colds ________ Colitis _________ Stiff/swollen joints ___________ Eyes Diarrhea/constipation _________ Arthritis ___________ Loss of vision ________ Genito/Urinary Bone deformities ___________ Wear glasses/contacts _________ Kidney dysfunction _________ Skin Respiratory Freq.urinary tract infect. _________ Severe acne __________ Asthma _________ Menstrual difficulty _________ Eczema __________ Tuberculosis _________ Severe cramps _________ Psoriasis __________ Other _________ Irregular menstrual cycle _________ Other persistent rash __________ Cardiovascular Pregnancy _________ Change in mole __________ Heart attack _________ Endocrine Emotional Heart disease _________ Under/Overactive Thyroid ________ Severe/persist. Depression __________ Hypertension _________ Diabetes ________ Severe/persist. Anxiety __________ Clotting abnormality _________ Neurological Attempted Suicide __________ Anemia _________ Seizures _________ Under Psych. Care __________ Gastrointestinal Epilepsy _________ Substance abuse __________ Freq. Abdominal Pain _________ Severe headaches _________ Need counseling __________Name:Date: PHYSICAL EXAMINATION (To be completed by health care provider) Height___________Weight___________Blood Pressure______________ Eyes/Vision R________L_________NormalAbnormalRemarks Ears/HearingNoseMouth/ThroatTeethNeckChestHeart LungsAbdomenBack Extremities Neurological SkinGenito, uro, rectal (if indicated)Comments/Recommendations:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Does the student have any emotional or physical problems which would limit him/her from taking a full academic programs? Explain:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Print Name: __________________________________Signature: ____________________________________Phone: _______________________ (Health Care Provider) Address: _________________________________________________________________________________Fax: __________________________TB Test Laboratory Test Tuberculin Testing Complete Blood Count Urine Analysis Date Given______________________ Hemoglobin________________________ Glucose_______________________ Date Read_______________________ WBC _____________________________ Albumin_______________________ Results__________________________ RBC______________________________ Ph____________________________Chest X-Ray if indicated: Other Tests, Abnormals________________ Color/Character____________________________________________________ ___________________________________ _________________________________________________________________ ___________________________________ _____________________________Name: ________________________________________________________________________________________________________________IMMUNIZATION RECORD Please indicate legibly below the dates the following immunization were given. Attach supporting documents (photocopies) if examining health care provider is not the person who administered vaccines. Unless verified by a health care provider, a statement that the student has acquired immunity through having had a particular disease is not acceptable. (This is a federal and state guideline for immunization policy.)DTP (diphtheria, tetanus, pertussis)- Series usually given in infancy and childhood.TD (tetanus, diphtheria)- Given in adulthood every ten years after initial childhood DTP series.MMR (measles, mumps and rubella)- Two doses are needed in childhood (no earlier than 12 months of age or closer together than one month.) Persons born before 1957 are considered immune. Polio – Series usually given in infancy and childhood. Meningococcal (meningitis)- Required by the state of Maryland by students in on campus housing unless waiver is signed. Hepatitis B- Given to adults in three doses. The 2nd dose is given one month after the 1st dose. The 3rd dose is usually given 6 months later, but no sooner than 2 months after the 2nd dose. Varicella (chickenpox)- Immunity can be shown by a positive titer. If titer does not demonstrate immunity, then two doses of vaccine are required. Dates of VaccinesDose No.DTPTD*PolioMMR*Meningococcal Hep. B**Varicella**123456*Required for all students. **Required for nursing and respiratory care students, recommended for all students.DiseaseResults Immune: YES NO123______________________________________________________________________________________________Signature of health care provider (administration/verification)DateAUTHORIZATION TO TREAT MINORSThe following permit must be signed by parent/guardian and notarized by a notary public, if the student is under 18 years of age: I hereby authorize and give consent to the health authorities or any licensed health care provider of Washington Adventist University to perform upon or administer to my son/daughter) ___________________________________any necessary medical or surgical treatment, examination, vaccines or anesthetics. In the event of any major medical or surgical problem, the University will attempt to contact me by phone or mail prior to the use of this authorization. It is not intended that any of the above mentioned services will be rendered to my son/daughter without his/her consent unless unable to do so (unconsciousness, etc.). This permit is valid only while the student is attending WAU and until he/she reaches the age of 18. __________________________________________________________________________________________________Name (Print)SignatureDate Address______________________________________________________________Phone _________________________________Witness(Print)______________________________________________ Signature _________________________________________