Keeping Horned Frogs Healthy

Texas Christian University Brown Lupton Health Center 817.257.7940 Phone817.2 57.7279 Fax www .healthcenter.tcu.edu

Return Completed Forms to: Mail: TCU Health Center

TCU Box 297400 Fort Worth, TX 76129

Fax: 817.257.7279Email: healthinfo@tcu.edu

TCU STUDENT HEALTH FORM

Name ______________________________________________________________________________________Date of birth:_______\_______\_______ Last First Middle Initial Month Day Year

Gender : Male Female Cell (______________)__________________________________TCU ID #________________________________

Entering TCU: Fall Spring Summer ~ Year 20__________ Incoming as: Undergraduate Graduate Other

Home Address_____________________________________________________________________________________________________________________ Street City State Zip Country

Emergency Contact:______________________________________________________________________________________________________________ Last Name First Name Phone Number

Relation to you: Parent Grandparent Spouse Brother/Sister Other (explain)

Are you a veteran? Y N If yes, have you been deployed in the past 12 months? Y N

List all current medications, prescription and "over-the-counter". Include: Asprin, Tylenol, Motrin, vitamins,

herbs, patches, creams/gels, implants, nasal sprays and inhalers.

Are you allergic to medications? Latex? Insects? Food? Do you carry an Epi Pen? Y N

Please list all allergies

Personal Medical History:

DiabetesHearing DeficitGlasses/ContactsHeadachesHead Injury/ConcussionHepatitisHigh Blood PressureKidney DiseaseLiver Disease

Thyroid ProblemsSplenectomyTuberculosisOther _________________

Allergies(seasonal)Aids/HIVAnemiaAsthmaBack ProblemBlood DisorderChicken PoxCancer (__________)Cardiac Abnormalities

MononucleosisMuscle/Joint/Chronic PainPhysical LimitationsRespiratory ProblemsRheumatoid ArthritisSeizure DisordersSerious InjuriesSkin DisordersStomach or Intestinal Problem

Explain any items you have checked and give dates if applicable:

Personal Mental Health History: Mental Health Hospitalizations/Treatment :

Do you intend to begin or continue psychotherapy during college? Y N Have you been hospitalized for a psychiatric disorder? Y N Have you been treated for alcohol and/or drug addiction? Y N

ADD/ADHDAlcohol/Substance AbuseAnger Problems Anti-Social Behavior Anxiety Disorder Asperger’s Autism Bi-Polar

Eating DisorderLearning DisorderObsessive-CompulsivePTSD Schizophrenia Self Mutilation Sleep Disorder Suicide Attempts Depression

C

Past Surgeries AND Hospitalizations:

(Give Dates)

B

A

E

Past Mental Health Hospitalizations:

(Give Dates)

D

PARENTAL CONSENT FOR MINORS:I hereby grant permission for the TCU Health Center staff to provide_______________________________(name of student) appropriate medical treatment, including medications for treatment, as a result of illness and/or injury, and to arrange for emergency medical care if circumstances arise. Parent/GuardianName:________________________________________________________Date___________________

Have you been vaccinated against tuberculosis (BCG)? Yes No

F Family History:

(Health Status=E –Excellent, G –Good, F-Fair, P-Poor, D-Deceased)

Relation Age Health

Status

Occupation Age of

Death

Cause of

Death

Father

Mother

Brothers

Sisters

Family Medical History:

(Relationship= M-Mother, F-Father, S-Sibling, MGP-Mother’s Parents, PGP-Father’s Parents, O-Other)

Do you have a family history of: Type Relationship Alcohol/Substance Abuse

Cancer Death Before 50 Diabetes

Heart Disease

High Blood Pressure

High Cholesterol

Mental Illness

Stroke/Blood Clot Thyroid Disease

Are you Adopted Y N

Two immunizations for Measles, Mumps, and Rubella (MMR). Students born before January 1, 1957 must submit proof of at least One MMR vaccination.

In addition to the Meningitis Requirement, official immunization records MUST BE SUBMITTED with the TCU Student Health Form and reflect the following:

Immunization records will be accepted from the following: A) Documentation bearing the signature of a licensed healthcare provider.B) Official Immunization record generated from a state or local health authority.C) Official record received from school officials.

G MANDATORY REQUIREMENTS FOR ALL INCOMING STUDENTS

Per Texas State Law, all entering (new and transfer) students, as well as students re-enrolling following a fall or spring semester break in TCU enrollment,

MUST SUBMIT DOCUMENTATION of having been vaccinated against BACTERIAL MENINGITIS (MCV4 or MPSV4) WITHIN THE LAST FIVE YEARS.

If you fail to satisfy this requirement you will not be able to enroll in class or apply for TCU Housing.*Students over 22 are exempt from this requirement*

Download the required Mandatory Bacterial Meningitis Vaccination Form and Student Health Form by visiting us online at www.healthcenter.tcu.edu.

Tuberculosis (TB ) Screening Questionnaire:

A. Have you ever had a positive TB skin test? YYYYY

N B. Have you ever been treated for TB? N C. Have you ever had close contact with anyone who was sick with TB? N D. Were you born in one of the countries listed below? If so, circle the country. N E. Have you recently traveled to/in one of the countries listed below? If so, circle the country. N

Afghanistan, Algeria, Angola, Armenia, Azerbaijan, Bangladesh, Belarus, Benin, Bhutan, Bolivia, Bosnia & Herzegovina, Botswana, Brunei Darussalam, Burkina Faso, Burundi, Cambodia, Cameroon, Cape Verde, Central African Republic, Chad, China, China-Macao, China-Hong Kong, Congo, Congo DR, Cote d’Ivoire, Djibouti, Dominican Rep., Ecuador, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Gambia, Georgia, Ghana, Guatemala, Guinea, Guinea-Bissau, Guyana, Haiti, Honduras, India, Indonesia, Iraq, Kazakhstan, Kenya, Kiribati, Korea-DPR, Korea-Rep, Kyrgyzstan, Lao PDR, Latvia, Lesotho, Liberia, Lithuania, Republic of Macedonia, Madagascar, Malawi, Malaysia, Mali, Marshall Islands, Mauritania, Micronesia, Moldova-Rep, Mongolia, Morocco, Mozambique, Myanmar, Namibia, Nepal, Niger, Nigeria, Northern Mariana Islands, Pakistan,Papua New Guinea, Paraguay, Palau, Peru, Philippines, Qatar, Romania, Russian Federation, Rwanda, Sao T ome & Principe, Senegal, Sierra Leone, Solomon Islands, Somalia, South Africa, Sri Lanka, Sudan, Suriname, Swaziland, Taiwan, Tajikistan, Tanzania-UR, Thailand, Timor-Leste, Togo, Turkmenistan, Tuvalu, Uganda, Ukraine, Uzbekistan, Vanuatu, Vietnam, Yemen, Zambia, Zimbabwe.

If you answer NO to all of the questions in box H, no further action is required.

If you answered YES to any question in box H, the TCU Health Center may contact you regarding further evalua tion.

H