Download ______________

Bridgewater State University Health and Counseling Form
Name ____________________________ Banner ID# ______________ Date of Birth_______________(mm/dd/yy)
International Home Address____________________________________________________________________________
Address while at BSU (street)____________________________(city)_____________________ (state)______(zip)________
Cell phone __________________
EMERGENCY CONTACT (name) ________________________(phone)_____________(relationship) ______________
Health Insurance Company______________________ Health Insurance ID #________________________________
IMMUNIZATIONS REQUIRED (MA State Law)
TUBERCULOSIS (TB) TESTING
Photocopies on Letterhead are acceptable. (Please attach.)
Immunization
Date of Immunization
Month/year
Tetanus with pertussis within 10 years
Measles, Mumps, Rubella (M.M.R.)
Documentation of (2) doses of measles, mumps,
Lab evidence (blood tests) of immune titers
if positive, satisfy the requirement.
TB questions below MUST be answered (CIRCLE Y or N)
Tdap ________________
3 dose series
If unable to document hepatitis B
Immunization, laboratory evidence of
immune titers must be submitted
Varicella Disease_________________
Have you ever had close contact with anyone
who was sick with TB?
Y
N
Y
N
Y
N
Y
N
Africa, Asia except Japan, Central /South
America, Mexico, Eastern Europe,
Caribbean, Middle East for more than one
1 ________________
Were you born in Africa, Asia except Japan,
2 ________________
Central/South America, Mexico,
Eastern Europe, Caribbean, Middle East?
3 ________________
(If yes, circle the region listed above)?
Have you ever been vaccinated with BCG
vaccine?
1______________
(For International visitors or students living on campus)
or
N
month within the last 5 years?
Meningococcal Vaccine*Within 5 years
Varicella Vaccine
Y
Have you ever resided in or traveled to
1 ________________
2 ________________
Titers?
Hepatitis B Series
Have you ever had a positive TB skin test?
1 ________________
2 ________________
Physician’s Signature___________________________________
TB testing is only required for people in high risk regions
or people answering yes to one of the questions above. US
citizens who answered no to the above questions are not
required to have proof of TB for university entry.
Tuberculosis Skin Test (PPD/Mantoux test)
Date Given ___________ Date Read __________
Results: Neg. ___ Pos.____
Date of Physician’s Signature ________________
Chest x-ray is required if PPD is positive.
*Residential Students may not gain access to housing without proof of
meningitis immunization within the last five years or a signed waiver
which acknowledges the risk but declines the immunization
X-ray Date____________
X-ray Results: Neg. ___ Pos.___
Treament?________
Allergies to Medication: List and be specific:
Allergies to Food: List and be specific:
DO YOU NEED TO CARRY AN EPI-PEN DO TO LIFE-THREATENING ALLERGIES? (circle
SIGNATURE___________________________________
1
one) YES
NO
Personal History (to be filled in by the international visitor)
Have you ever…. Please Circle YES or NO (then explain each yes answer in the box below*)
1.
2.
3.
4.
Been hospitalized or had surgery?.............................................................................Yes
Had a head injury resulting in unconsciousness or temporary memory loss?................ Yes
Had migraine headaches?........................................................................................ Yes
Suspected or been told you might have an eating disorder:
a) Anorexia nervosa?.................................................................................... Yes
b) Bulimia?.................................................................................................. Yes
c) Compulsive overeating?............................................................................ Yes
d) Other?..................................................................................................... Yes
Had counseling or treatment for an emotional problem? Yes
No
Had any of the following conditions:
a) Asthma?.................................................................................................. Yes
b) Anemia?.................................................................................................. Yes
c) Diabetes?................................................................................................. Yes
d) High Blood Pressure?................................................................................ Yes
e) Heart Murmur/Arrhythmias?...................................................................... Yes
f)
Hemophilia/Bleeding Disorder?.................................................................. Yes
g) Hepatitis/Jaundice?................................................................................... Yes
h) Kidney Disease?....................................................................................... Yes
i)
Mononucleosis?........................................................................................ Yes
j)
Rheumatic Fever?..................................................................................... Yes
Had a chronic medical condition not otherwise mentioned on this report?................... Yes
5.
6.
7.
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
*Explain any Yes answers from above:
Family History (to be filled in by the international visitor)
Do you have a family history of any of the following conditions? (parents or siblings)
Yes
1. Anemia
2. Diabetes
3. High Blood Pressure
FAMILY
HISTORY
Age
4.
5.
6.
7.
8.
Any Health Problems:
Father
No
Heart Disease before age 65
Stroke before age 65
Sudden death before age 50
Alcohol or Drug problem
Emotional /psychiatric illness
Mother
Brother(s)
Sister(s)
A Physical Exam is RECOMMENDED BUT NOT REQUIRED.
If you have had a recent physical, you may attach a copy of that exam.
Please return this form, proof of immunization and the optional physical exam by mail, FAX, or email to:
International Student and Scholar Services
Dr. E Minnock Center for International Engagement
Maxwell Library, Rm. 330
10 Shaw Road,
Bridgewater, MA 02325 USA
Phone: (508) 531-6195
FAX:
(508) 531-4135
Email: [email protected]
It is Massachusetts Law that we must receive this information at least 2
weeks before coming to campus.
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