Health Form A | University of Bridgeport

PART A: STUDENT INFORMATION

PLEASE PRINT ALL INFORMATION

Last Name First Name Middle Initial

Cell Phone Home Phone

Birth Date

DDMM YY Y Y

Birthplace

Permanent Home Address City State ZIP Code

Mailing Address City State ZIP Code

Marital Status: Single Widowed Married Divorced

Major Date of entry to U.S.

DDMM YY Y Y

Varsity Team Sport(s) Gender:

Male

Female

IN CASE OF EMERGENCY, NOTIFY:

Last Name First Name Relationship

Address City State ZIP Code

Business Phone Home Phone Cell Phone

I hereby grant permission to the Health Services personnel to contact the person named above in the event of a medical emergency.

Student Signature

Date

DDMM YY Y Y

MANDATORY INSURANCE COVERAGE

The University of Bridgeport Health Insurance policy is mandatory for all international students, all students in campus housing, students in the Physician Assistant program,

and all full-time undergraduate students. Only domestic students have the option to apply for an insurance waiver. Waivers will only be approved if the domestic student

provides documentation of comparable health insurance and a valid insurance card.

UNIVERSITY OF BRIDGEPORT

STUDENT HEALTH SERVICES HEALTH FORM A

MANDATORY FOR ALL UNDERGRADUATES, HEALTH SCIENCES STUDENTS, AND INTERNATIONAL STUDENTS

The appropriate health report must be submitted by all students with the exception of distance learning. Registration at the University cannot be conﬁrmed until this form

has been accepted as complete by Student Health Services. Parts A and B should be completed by the student prior to being examined by the physician/health care provider.

Entering Semester: Fall Spring

YY Y Y

Status: Resident Oﬀ-campus student

University of Bridgeport Student ID UB Email Program

Students joining NCAA teams should ﬁll out the sports form that can be found on bridgeport.edu.

STUDENT HEALTH SERVICES

Name: Date of Birth:

PART B: STUDENT AUTHORIZATION FOR TREATMENT AT UB HEALTH SERVICES

I hereby authorize the University of Bridgeport Student Health Services to provide medical treatment and services as they deem appropriate. This authorization will remain

in eﬀect as long as I am a registered student at the University of Bridgeport.

Student Signature

Date

DDMM YY Y Y

(Must be 18 years of age or older)

Signature of Parent or Guardian Date

DDMM YY Y Y

(If student is under 18 years of age)

STUDENT CONSENT FOR TREATMENT REQUIRED TO BE SIGNED

(if you are less than 18 years of age, signatures of both the student and one parent/guardian are required)

I hereby grant permission for the University of Bridgeport Health Services staﬀ to provide me with appropriate medical and mental health treatment including medications

for treatment of illnesses/injuries and to arrange for any emergency medical care if circumstances at that time make it impossible to make such decisions.

Signature of Parent or Guardian

Date

DDMM YY Y Y

Following the prompt completion of this medical form, mail, fax, or email a scanned copy to the following address:

University of Bridgeport Tel: 203.576.4712

Student Health Services Fax: 203.576.4715

60 Lafayette Street, Room 116 Email: healthservices@bridgeport.edu

Bridgeport, CT 06604

PART C: VACCINE REQUIREMENTS FOR ALL STUDENTS

THIS SECTION IS TO BE COMPLETED BY THE PHYSICIAN/HEALTH CARE PROVIDER AND IS MANDATORY FOR ALL

STUDENTS.

The following immunizations and tests are mandatory prior to registration and to reside in on-campus housing.

Meningococcal Vaccine (A, C, Y, W-135)

DDMM YY Y Y

Mandatory if living on campus, must have been given in past 5 years.

MMR (Measles, Mumps, Rubella) Not required for students born before January l, 1957.

Two measles, mumps, and rubella vaccines are required. Both vaccination dates must be listed.

DDMM YY Y Y

1st Immunization (First vaccine at or after 12 months of age or after 1/1/69) 2nd Immunization (Second vaccine required on or after 1/1/80)

OR Antibody titer for measles, mumps, and rubella

You must provide proof of immunity with lab slip. Attach lab slip if titer is being used to complete this requirement.

Varicella (Chickenpox) Not required for students born in the United States before 1980.

Two varicella vaccines are required. Both vaccination dates must be listed.

DDMM YY Y Y

1st Immunization Date 2nd Immunization Date

(Second dose given at least 12 weeks after ﬁrst dose, if that was given at 1–12 years, or at least 4 weeks after ﬁrst dose, if that was given at 13 years or older)

OR Antibody titer for varicella You must provide proof of immunity with lab slip. Attach lab slip if titer is being used to complete this requirement.

OR Conﬁrmed case of disease by physician/health care provider or public health director in student’s present/previous town of residence.

DDMM YY Y Y

Date of Illness

COVID-19 Vaccine Type

1st Dose

DDMM YY Y Y

2nd Dose

DDMM YY Y Y

Booster Yes No

DDMM YY Y Y

Tuberculin/PPD or IGRA Interferon Gamma Release Assay

Required within 6 months of registration. History of having BCG vaccine is not considered a contraindication.

PPD Date Given

DDMM YY Y Y

PPD Date Read

DDMM YY Y Y

Result MM

IGRA Date

DDMM YY Y Y

Result

Any history of positive PPD?

Yes Date

DDMM YY Y Y

PART D: REQUIRED FOR ALL CLINICAL HEALTH SCIENCE AND NURSING STUDENTS

(Excluding Pre-Nursing)

SELECT ONE PROGRAM:

School of Chiropractic

Fones School of Dental Hygiene

Medical Lab Science

Physician Assistant Institute

Acupuncture Institute

School of Nursing

Pre-Dental Hygiene

VACCINES REQUIRED

Tetanus, Diphtheria Pertussis (TdaP) Must be within the past 10 years.

DDMM YY Y Y

Hepatitis-B Vaccine Series of 3 doses

DDMM YY Y Y

Dose #1 Dose #2 Dose #3

Hepatitis-B/Quantitative Titer (Must attach titer)

Flu Vaccine

DDMM YY Y Y

TUBERCULOSIS SCREENING REQUIRED Two-Step PPD or IGRA

PPD Tuberculin skin test (Mantoux) Two-step PPD required (1–3 weeks apart)

PPD #1

DDMM YY Y Y

Result mm duration Positive Negative

Date placed Date read

PPD #2

DDMM YY Y Y

Result mm duration Positive Negative

Date placed Date read

If PPD is positive at either reading, a chest x-ray is required and “Tuberculosis–Statement of Treatment”* must be ﬁlled out by the provider.

*Form can be found at bridgeport.edu/healthforms.

Blood Assay for M. tuberculosis (IGRA)

Provide documentation of a negative IGRA performed within the previous 6 months Yes No

IGRA date

DDMM YY Y Y

Result Positive Intermediate Negative

If IGRA is positive, a chest x-ray is required and “Tuberculosis–Statement of Treatment”* must be ﬁlled out by the provider. *Form can be found at bridgeport.edu/healthforms.

PART C: VACCINE REQUIREMENTS CONTINUED

If positive history of PPD or IGRA, the following information is MANDATORY.

1. Prophylactic treatment dates

DDMM YY Y Y

OR Reason for non-treatment

2. Chest x-ray required if PPD not done or if skin test/IGRA is positive. Chest x-ray date

DDMM YY Y Y

Result

RECOMMENDED VACCINES

Flu Vaccine

DDMM YY Y Y

It is highly recommended that students obtain the health requirements and health records of the vaccines from their primary doctor.

Some vaccines are not available in UB Student Health Services and may be high in cost.

PART E: TO THE PHYSICIAN/HEALTH CARE PROVIDER

This section is to be completed by the physician/health care provider and is mandatory for all students. Please review the student’s history and complete the

Health Examination Report. This information will be used only as background for providing health care and will not be released without the student’s consent.

I have examined Date

DDMM YY Y Y

Last Name First Name Middle Initial

History of present illness (i.e., asthma, diabetes)

Current or past medical history (i.e., illnesses, surgeries, injuries, psychiatric conditions)

PART E: TO THE PHYSICIAN/HEALTH CARE PROVIDER CONTINUED

Social history

Indicate location and dates of travel within the past year

Family medical history (i.e., diabetes, hypertension, heart disease, cancer, etc.)

List all allergies (including medication, insect venom, etc.)

Comment on type of reaction (i.e., rash, urticaria, anaphylaxis)

List all medications currently being taken, including vitamins and supplements

If the student has a severe food allergy, please encourage him/her to take a tour of allergy-friendly options on campus by emailing diningservices@bridgeport.edu

Is the student allergic to latex? Yes No Is an EpiPen prescribed? Yes No

Does the student wear glasses/contacts? Glasses Contacts

DDMM YY Y Y

Specify reason

Date of last eye exam

PHYSICAL EXAM

Weight

Height

Glasses

Contacts

General

Skin

HEENT

Neck

Lungs

Heart

Chest

Blood Pressure

Pulse Temp

Extremities

Vision (R) (L)

Hearing (R) (L)

Back/Spine

Genito/Urinary

Vascular

Lymphatic

Neurologic

Abdomen

URINALYSIS

Protein Sugar Blood Other

Laboratory Findings

HGB or HCT Any other lab results

Status of student’s physical restrictions: Unrestricted Partial restriction Full restriction

Comments

Are there any limitations regarding this student’s participation in school or residing on campus? Yes No

If yes, please specify

Clinical impression

Recommendations

PHYSICIAN/HEALTH CARE PROVIDER’S INFORMATION (please print)

Last Name First Name Middle Initial Telephone

Address City State ZIP Code

Physician/Health Care Provider’s Signature Date of Exam

DDMM YY Y Y