Student Health Information Form Personal Health History

Fort Dodge Center One Triton Circle Fort Dodge, Iowa 50501
(515)-574-1047
1-800-362-2793
Student Health Information Form
Fall
Spring Year _________
Health form is required to be completed by all students entering Iowa Central Community College as freshman or
transferring in from another college.
Name: _____________________________________________
Male Female
Last
First
MI
Home Address: _____________________________________________________________________________________
Street
City
Date of Birth: __________________
State
Zip
Student Phone Number: ______________________________________
Emergency Contact: _________________________________________________________________________________
Name
Relationship
Home/Cell Phone #:______________________________
Address
Work Phone #: _________________________________
Family Physician: ____________________________________________________________________________________
Name
Address
Phone #
Medical Insurance: (Please enclose a copy of your insurance card) ___________________________________________
Company
Policy #
I will remain under my current health insurance plan while attending Iowa Central Community College.
I currently have no medical insurance.
Personal Health History
Do you have, have you had?
Yes
Asthma
Chicken Pox
Epilepsy/Seizures
High/Low Blood Pressure
Heart Disease
Urinary Tract Problems
Ulcers
Trouble Sleeping
No
Yes
Frequent anxiety
Chest Pain/Pressure
Frequent Depression
Mumps
Kidney Disease
Mononucleosis
Frequent Respiratory Illnesses
Dizziness/Fainting
No
Yes
No
Cancer
Diabetes
Head Injury
Headaches (migraines)
Tuberculosis
Sexually Transmitted Infections
Females: Irregular/Painful Periods
Weakness/Paralysis
Please explain all “Yes” responses:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Is there any other significant health information we need to know about you?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Medications (Please list any medications taken regularly):
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Allergies (Please list any drug , environmental or other allergies you may have):
__________________________________________________________________________________________________
OVER
Immunization Information
Must be completed by all students born after 1956.
Proof of immunizations or immunity is required to attend Iowa Central Community College. It is required that you
provide Health Services with a copy of your immunization records obtained from your family doctor or local health
department. If Health Services does not receive your health information form & a copy of your immunization
records, you will not be allowed to register for next semester classes.
**Health Science students must follow the requirements of immunizations for the Health Science department. Please
check with them upon admission.
REQURED IMMUNIZATIONS OF ALL NEW STUDENTS (Including transfer students)
 Measles (Rubeola) Immunity: (Please check one of the following options)
1. I have had two doses of live measles vaccine (MMR). Two doses are required for admission. (See Record)
First Dose must be on or after 1st birthday.
Second Dose must be given in 1980 or later and at least 30 days after the first.
I have had Measles (Rubeola) disease. ________________________________________
Year
2. I am exempt because I was born before January 1, 1957.
 Tuberculosis (TB) Testing is required for all Non-U.S. Citizens after arriving in the United States or for anyone
who has traveled outside the United States in the past 12 months.
Date administered ____________________ By _____________________________ Site _________________
Date read __________________ By _______________________________ Results ______________________
This test is available through the Health Services Offices if needed for a fee.
 Meningitis: (Please check one of the following options)
1. I have been vaccinated (See Record).
2. I have not been vaccinated. I have been informed and have reviewed the Vaccine Information Statement
provided about the Meningococcal Disease and the Meningococcal Vaccine and am refusing to be
vaccinated at this time. By signing this I am showing that I have been informed of the Meningococcal
Disease and have not been vaccinated and I am refusing the vaccination at this time.
____________________________________________
______________________
Signature
Date
RECOMMENDED IMMUNIZATIONS
 Hepatitis B – Hepatitis B vaccine is to protect against Hepatitis B which is transmitted via blood or body fluids by
sexual contact, exposure to blood or body fluid, sharing of needles, etc. This is a 3-shot series.
 Varicella- Varicella vaccine protects against the chicken pox virus. Either a history of chicken pox or two doses
of vaccine given at least one month apart if immunized after age 13 years meets the recommendation.
 Tetanus – It is required for children to have the tetanus series for elementary school enrollment. It is
recommended students receive a booster shot upon entrance into college. This series would fulfill the
recommendation for college. Normally tetanus is a 4-5 shot series plus boosters every 10 years.
 Polio - It is required for children to have the polio series for elementary school enrollment. That series would
fulfill the recommendation for college. Normally polio is a 3-4 shot series.
Consent: I hereby state that the above information is true and give permission for Health Services to release information to any
Iowa Central Community College staff including but not limited to administration, athletic trainers, campus counselor, housing staff,
and/or teaching staff, and to health care providers or facilities on a need to know basis.
In case of an accident or an emergency in which I may be unable to direct my own medical care, I authorize Iowa Central Community
College to seek appropriate medical/surgical care for me until those identified as emergency contact persons can be notified
If under 18, must be signed by both student and parent/guardian.
Student’s Signature __________________________________________
Date _____________________
Parent/Guardian Signature ____________________________________
Date _____________________