Franciscan University of Steubenville
Confidential Health Record Form
Student Health Services
OFFICE USE ONLY
Deposit: ______________________________
Fall 20____: _________________________
Spring 20____: ______________________
Student ID: __________________________
University Wellness Center
Franciscan University of Steubenville
1235 University Blvd. • Steubenville, OH 43952-1763
740-284-7223 • Fax: 740-422-0925
Student Health Record
This is a confidential communication between the student and Franciscan University Wellness Center.
Information herein will not be transmitted to anyone without the written consent of the student.
This form must be completed in full and returned to the University Wellness Center in the enclosed envelope.
Part 1: Please answer all questions. Consult your physician or parents if necessary.
1. Student Information
Please Print
Name: __________________________________________________________________________________________________ Male
❑
Female
❑
Birth Date: __________ / __________ / _________
Last First Middle
Home Address: ________________________________________________________________________________________ Social Security #: ___________________________________________________
City: ____________________________________________________________________________________________________________________ State: ______________ ZIP: ________________________
Contact Information:
Home Phone: ______________________________________________ Mobile phone: ___________________________________________
Preferred email: _____________________________________________
2. Person to Notify in Case of Emergency
Name: ___________________________________________________________________ Relationship to student: ______________________________________________________
Telephone Numbers:
Home:
___________________________________
Mobile:
_____________________________________
Work:
__________________________________
3. Allergies
Allergies to medications: _____________________________________________________________________________________________________________________________________________________
Food Allergies/Other Allergies: ________________________________________________________________________________________________________________________________________________
4. List any prescribed medications and regularly used over-the-counter preparations: _________________________________________________
_________________________________________________________________________________________________________________________________________________________
Part 2: Personal Health History
All health information is confidential and kept separate from your academic records as required by law.
If you have ever had any of the following, comment below or explain on a separate sheet.
Alcohol/drug abuse
❑ Y ❑ N
Diabetes
❑ Y ❑ N
High blood pressure
❑ Y ❑ N
Tobacco use
❑ Y ❑ N
Anxiety/panic attacks
❑ Y ❑ N
Dental issues
❑ Y ❑ N
Headaches
❑ Y ❑ N
Tuberculosis
❑ Y ❑ N
Anemia
❑ Y ❑ N
Eating disorder
❑ Y ❑ N
Recurrent ear infections
❑ Y ❑ N
Vision concerns
❑ Y ❑ N
Asthma
❑ Y ❑ N
Head injury/concussions
❑ Y ❑ N
Recurrent sinusitis
❑ Y ❑ N
Urinary Tract infections
❑ Y ❑ N
Bleeding disorders
❑ Y ❑ N
Heart problems
❑ Y ❑ N
Seizures
❑ Y ❑ N
Bowel concerns
❑ Y ❑ N
Hepatitis
❑ Y ❑ N
STD’s
❑ Y ❑ N
Depression
❑ Y ❑ N
Hearing concerns
❑ Y ❑ N
Thyroid concerns
❑ Y ❑ N
List any disease, illness, injury, past surgeries (including transplants), permanent disabilities, or marked health concerns that Wellness Center sta should be aware of:
________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________
OVER
franciscan.edu/admissions
Revised 4/20
(Recommended within 10 years of enrollment)(Recommended within 10 years of enrollment)
Part 3: Immunizations
Complete the line items below with the Month/Day/Year of EACHEACH immunization.
Submit an official immunization record with this form. Submit an official immunization record with this form. Please attach.Please attach.
Tetanus/Diphtheria BoosterTetanus/Diphtheria Booster
________ / _______ / _____ , _____ / _______ / _________ , _____ / _____ / ________ , ______ / _________ / ________
M D YR M D YR M D YR M D YR
Haemophilus Inuenzae BHaemophilus Inuenzae B
________ / _______ / _____ , _____ / _______ / _________ , _____ / _____ / ________ , ______ / _________ / ________
M D YR M D YR M D YR M D YR
PolioPolio
________ / _______ / _____ , _____ / _______ / _________ , _____ / _____ / ________
M D YR M D YR M D YR
Hepatitis AHepatitis A
________ / _______ / _____ , _____ / _______ / ________
Measles/Mumps/RubellaMeasles/Mumps/Rubella
_____ / _____ / ________ , _____ / ________ / ________
M D YR M D YR M D YR M D YR
Tetanus/Diphtheria BoosterTetanus/Diphtheria Booster
________ / _______ / _____
VaricellaVaricella
_____ / _____ / _______ , _____ / ________ / ________
M D YR M D YR M D YR
Varicella Varicella (Chicken pox) (Chicken pox) Date of DiseaseDate of Disease ______ /
________ / __________
M D YR
Please Note: In order to live in one of our residence halls, you must complete the vaccination information below.
This is mandated by Ohio Law ORC 3701.
Meningococcal & Hepatitis B Vaccine Status (required by ORC 3701). Must be completed to live in any residence hall.
I have read and understand the information provided about these vaccines. I understand the risks/benets of being vaccinated against
these diseases. The information given below is accurate.
Meningococcal vaccine received
❑
Yes
❑
No Hepatitis B vaccine received
❑
Yes
❑
No
If No, MUSTMUST complete a waiver, available at franciscan.edu/health-services.
_________ / ________ / _____ , ______ / _________ / _________ ________ / ________ / _____, _____ / ________ / _________ , _____ / ________ / ________
Tuberculosis Risk Assessment:
A screening must be performed by a licensed medical doctor if you answer YES to items 1-3 below. If deemed
necessary by the physician, a TB test may be given and documented with date given, date read, and result, and preferably the name of the person who
read the result. If that TB test is positive, a chest X-ray will be required to determine the status of the illness.
1. Do you have unexplained fever for more than one week, unexplained weight loss, night sweats, persistent cough
for more than three weeks, or a cough productive of bloody sputum?
.........................................................................
❑ Y ❑ N
2. Do you have any of the following risk factors: contact with anyone with active tuberculosis, injected illegal drugs,
have HIV infection, are a past or present health care worker, have cancer, diabetes, kidney disease, or chronic
steroid use, been a resident, volunteer, or employee in a jail, prison, homeless shelter, nursing home, or hospital?
.................
❑ Y ❑ N
3. Were you born, have lived, or recently traveled (more than 1 month) outside of the United States?
.....................................
❑ Y ❑ N
If you answered YES to any of the above questions, you are REQUIRED to have PPD/Tuberculin Skin Testing within one year.
Date Placed
:
________________________ Date Read
:
____________________________ Results
:
______________________
*
If positive results, attach copy of chest X-ray. INH completed?
❑ Y ❑ N
Dates: ______________________________________
I certify that the information contained herein is complete and accurate to the best of my knowledge.
________________________________________________________________________ _____________________
Student Signature Date
Parent/Guardian Consent for Treatment of Student Under 18 Years Old:
I, ____________________________________________________ , parent/guardian of ________________________________________hereby give permission
for such diagnostic, therapeutic, and operative procedures deemed necessary for my child.
________________________________________________________________________ _____________________
Signature of Parent/Guardian Date
Complete both sides.