AT Program Student Health Form
Student Health Form _________________________________________________________________________________________________________ Last Name First MI Home Address: _______________________________________________________________________________________ Street City State Zip Code ______________________ ____________________ M F S M D W Date of Birth Social Security Number Sex Marital Status Home Phone _____________________ Cell Phone_______________________ Other__________________ _______________________________________________________________________________________ Name of Health Insurance Company & Group/Policy Number(s) (Please provide front/back copy of card) Parents Information: _______________________________________________________________________________________ Name of Parents, Guardians, or Spouse _______________________________________________________________________________________ Address: Street City State Zip Code Home Phone _____________________ Cell Phone ______________________ Other __________________ Immunization/Titer Required Healthcare Provider Hepatitis B Vaccine Date Given HCP Initials Dose #1 __________________ _______________________ Dose #2 (to be given 1 mo. after 1st Injection) __________________ _______________________ Dose #3 (to be given 6 mos. after 1st injection) __________________ _______________________ Tetanus Vaccine (within the last 10 years) __________________ _______________________ Below are only needed if the immunization records are incomplete. **MUMPS TITER (attach copy of lab report) **RUBEOLA (Red Measles) TITER (attach copy of lab report) **RUBELLA (German Measles) TITER (attach copy of lab report) **VARICELLA TITER (attach copy of lab report) ***HEPATITIS B TITER (attach copy of lab report) ** This titer must include IGG anitbody levels. *** This must be a QUANTITATIVE TITER and is to be drawn 30-60 days after the third injection. Past Medical/Surgical History Have you had surgery? List surgery dates. ______________________________________________________________________________________________ ________________________________________________________________________________________ Athletic Training Handbook 34 Are you presently on any medications? If so, list medication(s). ______________________________________________________________________________________________ ________________________________________________________________________________________ Have you been treated for any psychological/emotional problems? Give details. ______________________________________________________________________________________________ ________________________________________________________________________________________ Is there a family history of a bleeding disorder, cancer, hypertension, or diabetes? List and state relationship. ______________________________________________________________________________________________ ________________________________________________________________________________________ Do you have any current health problems/ limitations that will affect your ability to function as an athletic training student? Give details. ___________________________________________________________________________________________ ___________________________________________________________________________________________ Childhood Diseases Have you ever had? Mumps Yes No Chicken Pox Yes No Scarlet Fever Yes No Measles Yes No Diphtheria Yes No German Measles Yes No Note to Healthcare Provider: Health examination form may be completed by a physician, nurse practitioner, or a licensed physician's assistant. TB Skin Test Date Given HCP Initials Date Examined HCP Initials Part 1: _______________ ________________ ________________ _______________ Part 2: _______________ ________________ ________________ _______________ Chest X-RAY (If positive skin tests): Date: _______________ Results: __________________________________ HCP Initials ___________ Additional Information In case of serious illness or accident, I give Cumberland University or its representatives’ permission to secure medical and/or surgical care to include transportation to a doctor or hospital of their choice, injection, examination, medication, diagnostics, and surgery that is considered necessary for my good health. I agree to pay all medical costs not covered by my primary or secondary insurance coverage. Signature of Student __________________________________________ Date ________________ Parent of Guardian (if under age 18) _______________________________ Date_________________ Please note that your ability to begin your clinical rotations relies on completed information contained in this document and copies of medical records as requested above