Off Campus Studies Health Form - Houghton College
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2OFF CAMPUS STUDIES HEALTH FORM
FOR USE BY THE OFF-CAMPUS STUDIES OFFICE
Only needed for participants in East Meets West Honors, Honors in London,
and/or Highlander Wilderness Adventure.
Name: __________________________________________________________________ Sex: q M q F
Date of Birth _____/_____/_____
Check the experience(s) in which you are participating:
q East Meets West
q Honors in London
q Highlander Wilderness Adventure
(deadline July 31)
(deadline July 31)
(deadline July 1)
THE FOLLOWING MUST BE COMPLETED BY THE STUDENT PRIOR TO THE PHYSICAL EXAMINATION.
HEALTH HISTORY
Withholding medical information could result in dismissal from the off-campus experience.
1. BLOOD TYPE check one (if known):
q O+
q O-
q A+
q A-
q B+
q B-
q AB+
q AB-
2. Allergies ALERT (list all): q None
Medications: _________________________________________________________________________________________________________
Insect Stings: _________________________________________________________________________________________________________
Food: ________________________________________________________________________________________________________________
Environmental: ________________________________________________________________________________________________________
NOTE: If you have severe allergic reactions you must carry your own medicines for emergencies. This includes a bee sting kit. You must know how to use it.
For Highlander: Leaders are trained to use the kit, but can only do so when patient’s own doctor has provided the kit.
2. Physical limitations and emotional conditions (List and describe): q None
a.
Fractures or injuries: _______________________________________________________________________________________________
b. Current and past treatment for any physical condition: __________________________________________________________________
c.
Current and past treatment for any emotional or mental condition: _______________________________________________________
d. Eating disorder/treatment for eating disorder: _________________________________________________________________________
e.
Other: ____________________________________________________________________________________________________________
3. Medications you will bring with you (including over-the-counter): q None _____________________________________________________
4. Dietary Restrictions: q None ____________________________________________________________________________________________
IMMUNIZATION HISTORY/ DATES
To be completed by a physician, nurse practitioner or physician assistant.
Please complete immunization dates rather than attaching a sheet of immunization records.
REQUIRED FOR ALL: (month/year) Tetanus or Tetanus/Diphtheria booster (within 10 years of program end) _____/_____
OPTIONAL: (highly recommended for students in East meets West or London Honors)
MMR (1) _____/_____ (2) _____/_____
Polio: _____/_____
Hepatitis A (1) ____/____(2) ____/____
Hepatitis B (1) ____/____ (2) ____/____ (3) ____/___
Other ________________________________________________________________________________________________________________
PHYSICIAN’S SIGNATURE: I have reviewed the above information and have evaluated the student. The above information
is accurate and complete to the best of my knowledge and I believe the student to be physically and mentally fit to participate
in an off-campus experience. Please see attached recommendations if box is checked. q
________________________________________________ ________________________________________________ ______________
Signature
Print Name
Date
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