New Student Medical History And Physical Examination Form (Page 4 of 4) in pdf

Page 4 of 4

TUDENT

EDICAL

ISTORY AND

HYSICAL

XAMINATION

Lawrence University Health Services • 711 E. Boldt Way • Appleton, WI 54911‐0599 • Phone: 920‐832‐6574 • Fax: 920‐832‐7488

Tuberculosis (TB) Risk Assessment

(continued)

3. Interferon Gamma Release Assay (IGRA)

□

Date obtained:_____/_____/_____

Specify method:

QFT‐G

QFT‐GIT

Other

□

Result:

negative

positive

intermediate

4. Chest x‐ ‐ ‐ ‐ ray: (Required if TST or IGRA is positive)

□

Date of chest x‐ray: _____/_____/_____

Result:

normal

abnormal

LEARANCE

□

Cleared

□

_______________________________________________________

Cleared after completing evaluation/rehabilitation for:

____________________________________________________________________________________________________

□

____________________________________

__________________________________

Not cleared for:

Reason:

_____________________________________________________________________________________

Recommendations:

____________________________________________________________________________________________________

_________________________________________

This is to certify that, in my opinion,

is in good health except as noted above,

and is able to participate fully in academic work, physical education programs, and intercollegiate athletics.

__________________________________________________

____/____/______

Healthcare provider’s signature:

Date:

___________________________________________

Healthcare provider’s name (print/type):

______________________________________________________________

_________________________

Address:

Phone:

Wisconsin State Statute 36.25(46) requires that all students who will be residing in a campus residence hall receive yearly information regarding the risks

associated with Hepatitis B and Meningococcal disease and the effectiveness of the vaccines available to prevent these diseases. The student who resides

in campus housing must affirm whether he or she has received vaccinations against Hepatitis B and/or Meningococcal disease, and must provide the dates

of the vaccinations, if any. The parents of minor students must provide this information. Please have these dates available when you check into housing.

Lawrence University requires that the Hepatitis B vaccine be initiated as a condition for enrollment. Immunization for Meningitis is strongly encouraged. Both

vaccines are available on campus at the Landis Health Center, but it is recommended that students receive them prior to coming to campus.