Note to the Student:
Unless ALL required immunizations and physical examination are submitted you will be administratively withdrawn and a fee will be assessed for reinstatement.	WESTFIELD STATE COLLEGE 
STUDENT HEALTH FORM

SIDE 1 - TO BE FILLED OUT BY THE STUDENT
	     IMPORTANT
Return this form to:
WSC Health Services
P.O. Box 1630
Westfield, MA 
01086-1630
Fax: 413-572-5545	
REPORT OF MEDICAL HISTORY
Please complete before going for your physical examination.                                                            
Please Print:

Name: Last                                               First                     M.I.            Social Security Number/Student ID#                  Date of Birth

Home Address: Street                                             City                   State             Zip              Phone                     Cell Phone  

Next of Kin: Name/Relationship                                                      Home Phone                   Business Phone          Cell Phone     

Next of Kin: Name/Relationship                                                      Home Phone                   Business Phone          Cell Phone

Health Insurance Carrier                                                            Policy Number                                                        Card Holder	

Emergency:  Permission is hereby granted for the emergency use of anesthesia and emergency medical treatment for my minor.  
Every effort will be made to contact the parents.
                                                                             Signature: ______________________________________________________ 
                                                                                                             Parent or Legal Guardian
MEDICAL HISTORY: 
Drug Allergies: Yes____ No____ If YES, list drug and reaction:_________________________________________________

Other Allergies: seasonal, insects, foods etc:_________________________________________________________________
                                            Please check yes or no on each line.  
              History of:	Yes	No	              History of:	Yes	No	               History of:	Yes	No	
Anemia			Gastro Intestinal Problems			Strep Throat			
Asthma			Head Injury			Substance abuse/Alcoholism 			
Back Injury/Problem			Headaches (Recurrent)			Surgery			
Blood Transfusion			Hearing Deficit			  Appendectomy 			
Chickenpox: Date (if known):			Heart Murmur 			  Tonsillectomy			
Contact Lenses			Hepatitis			  Other surgery-comment below			
Depression/Anxiety			High Blood Pressure			Tobacco user			
Diabetes			Kidney Problem			Tuberculosis			
Disease/Injury of joints/bones			Learning Disability			Thyroid Disease			
Ear, Nose, Throat Problems			Mononucleosis			Urinary Tract Infection  			
Eating Disorders			Seizures			FEMALES ONLY:			
Eye Problems			Sickle Cell Trait			Birth Control			
Fainting			Skin Condition:			Menstrual Disorder			

Comments on medical/psychiatric history: _____________________________________________________________________________________________________

List any daily medications/condition for which medications are prescribed:  _____________________________________________________________________________________________________
_________________________________________________________________________________________
Special needs student: Nature of Disability/Special medical nursing needs: 
_________________________________________________________________________________________

   ____________________________________________        Will you live on campus?   Please circle-    Yes             No  
                      Student’s Signature                                  Date                                    

TO THE STUDENT: This information is confidential & will not be released without your knowledge and written consent.  The College will not be liable for any medical history information that is omitted from this form. 

SIDE 2 - TO BE FILLED OUT BY THE PHYSICIAN

Name:                                                                           DOB:                            	     Male  (   )   Female  (   )
*Please complete required Immunizations (Month & Year) & Physical Exam sections before mailing.
**Required for full time undergraduate, residential students or signed meningitis information waiver form must be submitted.
VACCINATIONS
 =  Required	DATE
Mo/Yr	DATE
Mo/Yr	DATE
Mo/Yr                	DATE
Mo/Yr	LABS
Urinalysis	
 *Tdap (booster within 10 years)    	#1				Glucose:	
 *MMR (2 doses required or titers)	#1.	#2.			Micro:	
  or *MMR titers
    Please circle results and note date	1.Measles     
   (Rubeola)
    Pos     Neg
Date:	2. Mumps
     Pos    Neg
Date:	3. Rubella
    Pos    Neg
Date:		Blood
Hgb.

Hct.	
 *Hepatitis B series 20mcg  or	#1.	#2.	#3.		             
           	
 *Hepatitis B 2 dose series 10mcg	#1.	#2.	                     or	 Immune Titer
Date:	
	
 **Menactra or Menomune
  Menomune date must be within 5yrs	    Menactra 	    Menomune			   	
 *Varicella/VAR if no history of chickenpox
          2 vaccinations required	#1.	#2.	  History of
  Chickenpox
Date:	 or Titer:		
 HPV Vaccine	#1.	#2.	 #3			
 PPD Mantoux TB Test: (see separate form)
     Follow MA State guidelines for risk:	Month/Year	 Neg        mm	 Pos       mm	If positive, chest x-ray report is required		
•	PHYSICAL EXAMINATION: Please review the information on Side 1 and complete this side. 

 HT: _________________       WT:_________________      BP: _________________      Pulse: _________________

SYSTEMS REVIEW:  Are there any abnormalities of the following?
	Yes	No		Yes	No	
	1.  Ears, Nose or Throat				7.  Genitourinary			
	2.  Eyes				8.  Musculoskeletal			
	3.  Respiratory				9.  Neuropsychiatric			
	4.  Cardiovascular				10.  Metabolic/endocrine			
	5.  Gastrointestinal				11.  Lymph			
	6.  Hernia				12.  Skin			
Comments:  	

Is the student now under treatment for any medical or emotional condition? Yes (   )     No (   )
Explain:  __________________________________________________________________________________________

Drug Allergies: Yes_____   No_____ If YES, list drug and reaction: ___________________________________________

Present Medications:	

Recommendations for physical activity:  Unlimited (   )     Limited (   )    Sickle Cell Trait: Yes (   )  No (   ) 
Is the student fit to participate in intercollegiate athletic competition?     Yes (   )     No (   )
Define activities to be restricted, if applicable:	
Physician’s Signature: ________________________________      Address: 	

Date: 	    City: 	
Printed Name: _____________________________________	    State: 	   Zip:  _________________ 
License # & State:	    Phone:	
MAIL FORMS TO ADDRESS ON FRONT SIDE             Questions: Phone 413-572-5415                Fax: 413-572-5545