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THE UNIVERSITY OF TEXAS AT DALLAS
STUDENT HEALTH SERVICE
CONSENT FOR TREATMENT
With few exceptions, you are entitled on your request to be informed about the information U.T. Dallas collects about you. Under Sections 552.021 and 522.023 of the Texas Government
Code, you are entitled to receive and review the information. Under Section 559.004 of the Texas Government Code, you are entitled to have U.T. Dallas correct information about you that is
held by us and that is incorrect.
NAME___________________________________________________ ID#__________________________
ADDRESS________________________________________________BIRTHDATE_____________________
CITY, STATE_______________________ZIP___________________
1. AUTHORIZATION FOR EXAMINATION AND TREATMENT:
The undersigned has been informed that examination procedures, and/or treatment considered necessary for the patient named on this
record will be performed by the Nurse Practitioner, Consulting Physician, or other employees of the UTD Student Health Service (AKA Student
Health Center). Authorization is hereby given for such treatments and procedures and the administration of such local anesthetics, medications, or
other treatment deemed necessary. I certify that I have read the above authorization, and understand the same and also certify that no guarantee or
assurance has been made as to the results that may be obtained. The Nurse Practitioners, Consulting Physician, appropriate staff and The University
of Texas at Dallas and its officers, regents, and employees shall not be responsible in any way for any consequences from said diagnostic, medical,
and/or surgical treatment and are hereby released from any and all claims and causes of action that may arise, grow out of, or be incident to such
diagnosis, treatment, or surgery insofar as the law allows and provided that these services are performed with ordinary care and to the best of their
ability.
2. ACKNOWLEDGEMENT OF OUTPATIENT TREATMENT:
I hereby understand and agree that the medical care that the medical care, which may be furnished to me in the UTD Student Health
Service, will be limited solely to outpatient treatment. I understand and agree that I may be released before all my medical problems are known or
treated and that it will be necessary for me to make arrangements for follow-up care.
3. RELEASE OF INFORMATION:
I hereby consent to the release of my medical information to authorized UTD Student Health Service staff, Counseling Center staff, and
consulting physicians, including those seen in the Health Center and/or those seen on a referral basis from the Health Center, also including hospital
Emergency Rooms and medical personnel with ambulance services.
4. ACKNOWLEDGEMENT OF REFERRAL SERVICES:
I hereby understand and agree that medical care and/or treatment deemed necessary for the undersigned may involve referral to specialty
physicians, Emergency Rooms, X-ray facilities, or other providers outside the UTD Health Center, and that any and all expenses for referral services
are the responsibility of the patient.
5. CONSENT TO PERMIT TESTING AFTER AN OCCURRENCE OF A BLOOD OR BODY FLUID EXCHANGE:
In the course of care and treatment within the UTD Health Center, health care workers may be accidentally exposed to a patient’s blood or
body fluids (through needle sticks, blood splatters, etc.). Communicable diseases, including the HIV virus that causes AIDS, are known to be
transmitted through accidental exposures of this type. When a health care worker is exposed to a patient’s blood or body fluid, the patient may be
required to be tested for HIV antibody and other communicable diseases in order to determine whether an actual exposure has occurred. This
information is necessary so that the health care worker can receive appropriate counseling and medical treatment. I understand and agree, that in the
event a health care worker is exposed to my blood or body fluids, my blood will be tested, at no cost to me, in a confidential manner, for HIV
antibody, and other communicable diseases. The results of these tests will not prejudice my patient relationship in the Student Health Center.
6. ACKNOWLEDGE BEING INFORMED ABOUT THE NOTICE OF PRIVACY PRACTICES:
I hereby acknowledge that I have been informed about the NOTICE OF PRIVACY PRACTICES of the UTD Student Health Service. This
information describes how my medical information may be used and disclosed and how I may have access to the information. HIPAA Privacy Rules
require that we furnish you with the notice.
____________________________________________
_______________________________
_____________________________
Signature of Patient/Authorized Person
Relationship
Date
____________________________________________
Signature of Witness
5-2008
Rev. 6-23-2011
_____________________________
Date
PERSONAL INFORMATION
Legal Name:
Last
First
Sex: M F Intersex Gender: Man Woman Other:________________
M.I.
Preferred Name: ____________________________________________________________
__________ ______________ Marital/Relationship Status:
Student I.D.#: __________
Current Address:
Permanent Address:
Age:____________
Street/P.O. Box
City, State, Zip
Street/P.O. Box
City, State, Zip
Date of Birth:________________________
Race (opt.): ______________________
Phone #: (
)
Cell #: (____)________________________________________________
Phone #: (
)
EMERGENCY CONTACT INFORMATION
Name:
Phone Number: (
Relationship to you:
)
MEDICINES YOU ARE TAKING
(List medicines, birth control pills, vitamins, herbal/dietary supplements and over the counter meds you take with or without a prescription)
DRUG AND/OR OTHER ALLERGIES
(List those you are allergic to and reactions)
HEALTH CARE PROVIDERS
Name of Family Health Care Provider:
Phone #: (
When was your last complete physical?
Year
)
Please list below anyone else you may have received healthcare from in the past:
Name of Doctor
or Other Provider
Location
City, State
Primary Problems Cared for
FAMILY HEALTH HISTORY
Has a relative (mother/father/sister/brother/grandparent) suffered from any of the following (check one):
DESCRIPTION
Abn. Bleeding Tendency
Cancer
Diabetes
Epilepsy/Seizures
Heart Disease
High Blood Pressure
History of stroke at
an early age (<50 yr.)
Tuberculosis
Other:
YES
[ ]
[ ]
[ ]
[ ]
[ ]
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NO
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RELATIONSHIP
In accordance with Leg. House Bill 1922, an individual is entitled to:
request to be informed about the information collected about them;
receive and review their information; and correct any incorrect
information.
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Do you smoke: [ ] Yes [ ] No
Packs per day:
PERSONAL HEALTH HISTORY
Number of years smoked:
More on back side of
form (please turn over)
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Does a member of your household smoke? [ ] Yes [ ] No
Interested in smoking cessation? [ ] Yes [ ] No
Alcohol use: [ ] Yes [ ] No
Frequency:
Amount/Type:
Drug Use (social): [ ] Yes [ ] No
Frequency:
Amount/Type:
Do you exercise? [ ] Yes [ ] No
Frequency:
Amount/Type:
On average, do you eat a healthy diet? [ ] Yes [ ] No Vegetarian [ ] Non-Vegetarian [ ]
Have you ever been a victim of domestic abuse or intimate partner violence? [ ] Yes [ ] No
Have you ever been sexually active: [ ] Yes [ ] No Number of partners in the past 12 months:
Have you ever had oral sex? [ ] Yes [ ] No
Have you ever had anal sex? [ ] Yes [ ] No
Sexual Orientation: [ ] Heterosexual [ ] Lesbian/Gay [ ] Bi-sexual [ ] Asexual
History of Sexually Transmitted Disease (STD): [ ] Yes [ ] No Type:
History of sexual contact with person(s) positive for STD: [ ] Yes [ ] No Type:
Method of Contraception: Abstinence / Birth control pills / DEPO / Patch / Other
Use of condoms to prevent STD/STI’s: [ ] Yes [ ] No
Age at first period:
How often do your periods occur?
Check One (regarding menstrual cycle)
Cycle: [ ] Regular
[ ] Irregular
Flow: [ ] Light
[ ] Medium
Pain: [ ] None
[ ] Mild
[ ] Heavy
[ ] Severe
[
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PREGNANCY HISTORY (females only
Enter the number of:
Times pregnant
Live births
Abortions/Miscarriages _________________
HAVE YOU BEEN TREATED BY A PHYSICIAN FOR ANY OF THE FOLLOWING?
] Abnormal Bleeding
] Alcoholism
] Anemia
] Anxiety
] Arthritis
] Asthma
] Cancer, tumor
] Chronic back problems
] Chronic cough
] Chronic skin problems
] Congenital heart disease
] Colitis/colon problems
] Depression
] Diabetes
] Diminished hearing
[ ] Dizziness/fainting spells
[ ] Drug abuse
[ ] Eczema, hives, rashes
[ ] Infectious mononucleosis
[ ] Kidney disease
[ ] Liver disease, hepatitis, yellow jaundice
[ ] Suicide attempt
[ ] Thyroid disease
[ ] Ulcer in stomach/duodenum
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[
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] Epilepsy/seizures/convulsions
] Eye problems
] Food allergies
] Gall bladder disease
] Glaucoma
] Hay fever/pollen allergies
] Heart disease
] Headaches
] Hepatitis
] Hernia
] High blood pressure
] Lung disease, tuberculosis
] Menstrual problems
] Mumps, measles, chickenpox
] Mental health concerns/mental illness
] Phlebitis
] Pneumonia
] Rheumatic fever
] Rubella, German measles
] Sinusitis
] Stomach problems/indigestion
] Stroke
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Has your physical activity been restricted during the past five years? (give reasons and duration) [ ] Yes
[ ] No
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Have you had difficulty with school, or studies? (give details)
[ ] No
[ ] Yes
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Have you ever received mental health counseling? (give detail)
[ ] Yes
[ ] No
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Have you had any illness or injury or been hospitalized other than already noted? (give details)
[ ] Yes
[ ] No
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Have you consulted or been treated by clinics, physicians, healers, or other practitioners within
the past five years? (Other than routine checkups)
[ ] Yes
[ ] No
] Unusual childhood illness
] Vision problems
] Weight-recent gain or loss
] Other illnesses
COMMENTS:
If, while at UTD, you will need any of the following, please indicate below and attach written
instructions from your physician:
[ ] Specialist Care for Chronic Illness
[ ] Maintenance Medication
Authorization for Treatment: I hereby certify that the above history is complete to the best of my knowledge and I
do hereby give permission for the UTD Student Health Service provider(s): doctors, nurse practitioners and nurses to
perform whatever diagnostic treatment, examinations, and procedures necessary to maintain my good health for as long as
I am a student at The University of Texas at Dallas.
I authorize UTD Student Health Services to release any medical and/or billing information to my insurance company,
necessary to process claims, relating to the care provided by this office.
If you are under age 18 years of age, your legal guardian must sign.
Signature of Student or Legal Guardian
Date