Student Health Record Siena College (Page 2 of 4) in pdf

Page 2

PLEASE COMPLETE THE FOLLOWING:

Hospitalizations or Operations (give dates & procedures)________________________________________________________________________

_____________________________________________________________________________________________________________________

Serious Injuries (including fractures, motor vehicle accidents, etc.)________________________________________________________________

_____________________________________________________________________________________________________________________

Counseling for Emotional Disorders/Psychiatric Treatment/Drug or Alcohol Rehabilitation____________________________________________

_____________________________________________________________________________________________________________________

Allergies (medications, food, environment; i.e., insects, chemicals, animals)_________________________________________________________

______________________________________________________________________________________________________________________

Medications:____________________________________________________________________________________________________________

Tobacco type/amount: _____________________________________________________________________________________________________

Alcohol use/amount: ____________________________________________________________________________________________________

THE INFORMATION I HAVE PROVIDED IS ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.

_________________________________________________ _______________________________

STUDENT SIGNATURE

DATE

_________________________________________________

_______________________________

PARENT SIGNATURE (if student is under 18 years of age) DATE

………………………………………………………………………………………………………………………………………………………….

FOR OFFICE USE ONLY

______M1 _______M2 _______MU ______RU ______MM _______TDaP

_______Parental Consent for Minors complete

_______ Medical History Page 1 &2 complete

_______ Physical Exam complete

________TB screen complete OR ______positive ppd w/ negative chest xray report

Reviewed by:________________________________________________ Date Health Record is complete_________________________________

(RN Signature)

Entered by____________________________________

______________________________________________________________________________________

Notes:

__________________________________________________________________________________________

Student Health Record Siena College Page 2