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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. 2 3 4