Hope College Health History Form

International Students
Hope College
Office of International Education
257 Columbia Ave
Holland, MI 49423
USA
Fax: 616-395-7937

HOPE COLLEGE
HEALTH HISTORY FORM

Instructions: This form is a requirement for entry to Hope College and Treatment in the Health Center.

Front side to be completed and signed by a health care professional.
Backside to be completed and signed by the Hope student. (Parent signature if under 18 years of age).
Return form by mail or fax to Hope College at above address BEFORE August 1, 2007 .
Note: All information is confidential and not part of academic records. The information is only accessible to the staff of the Health and Counseling Services, unless written authorization is provided in compliance with HIPAA regulations.

Last Name (Print), First Name, Middle

Permanent Address (Home), Street, City, State, Country

Country Arriving From
Age	Birthdate (month, day, year)	Female Male
Home Telephone (with country or area codes)

Required Immunization Series		Print dates each dose was provided in boxes below
Diphtheria	Combination Vaccine accepted. Minimum primary series of 3 doses and booster dose within the last 10 years.
Pertussis
Tetanus
Polio	Minimum of 4 doses required, last dose after 4 years of age.
Hepatitis B	Minimum of 3 doses required.
Measles (rubeola)	Combination Vaccine accepted. Minimum of 2 doses of each component required, 2 nd dose must be after 4 years of age.			Recommended Immunizations (Available at Hope College Health Center )
Mumps				Meningococcal (A,C,Y,W-135)	Date provided:
Rubella				Influenza	Provided at Hope College (Date/Type) #1 __________ ________ #2 __________ ________ #3 __________ ________ #4 __________ ________
Chickenpox (Varicella)	Did you have this disease already? Yes No If no…Varicella vaccine is required.	Date of Varicella Vaccine below	2 nd dose required if age 13 or older	Tetanus booster	Date/Type:

Required Health Care Professional's Signature

Print Name: ___________________________________	Title: _________________________________
Signature: ____________________________________	Date: _________________________________

PERSONAL & FAMILY HEALTH HISTORY

Height:

Weight:

Medications Allergies (List):

Medications taken regularly:

Hospitalizations/Surgeries:

Mark all that apply:

		Myself	Family
*AutoImmune Disorders:*
	Diabetes
	Multiple Sclerosis
	Systemic Lupus
	Other:________________________
*Blood Disorders:*
	Anemia
	Clotting Deficiency
	Other:________________________
*Cancer:*
	Specify:
*Cardio/Pulmonary Disorders:*
	Asthma
	Heart Murmur
	Heart Disease
	High Blood Pressure
	High Cholesterol
	Other:________________________
*Digestive Disorders:*
	Crohn's Disease
	GERD
	Irritable Bowel
	Peptic Ulcer
	Other:________________________
*Eating Disorders:*
	Anorexia Nervosa
	Binge Eating
	Bulimia
	Other:________________________
*Mental/Emotional Disorders:*
	Anxiety
	Depression
	Suicide Attempt
	Other:________________________
*Neurological Disorders:*
	ADD/ADHD
	Cerebral Palsy
	Migraine Headaches
	Seizures
	Other:________________________

IN CASE OF EMERGENCY CONTACT

NAME: _________________________________

Relationship: ____________________________

Phone # 1: ______________________________

Phone # 2: ______________________________

NAME: _________________________________

Relationship: _________________________

Phone # 1: ______________________________

Phone # 2: ______________________________

Other Immunization History - Indicate ONLY if already provided

BCG Vaccine

Date:____________

Hepatitis A

Date:____________
Date:____________
Date:____________

Typhoid

Date:____________
Date:____________
Date:____________

Yellow Fever

Date:____________
Date:____________
Date:____________

Other (Specify):

Name                                       Date

STATEMENT OF AUTHORIZATION

I Authorize the Student Health Center of Hope College to administer medical and surgical services, including immunizations and to perform routine and emergency diagnostic and therapeutic procedures as deemed necessary by duly licensed medical personnel. I understand that the Medical Director, or designee, serves as primary physician for medical care provided by the Hope Student Health Center.

I understand that I will be required to undergo medical treatment for any current or future diagnosis of Latent Tuberculosis Infection (LTBI). Failure to do so will result in withdrawal from current coursework and living arrangements at Hope College.

_________________________
Signature of Student

___________________
Date

____________________________________
Signature of Parent/Guardian if student is under age 18