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Student Health Form

Student Health Form

Personal & Emergency Information:
First Name:
Last Name:
E-mail Address:
HPU Student ID # (If known)
Gender:

Date of Birth
RadDatePicker
Open the calendar popup.
 
Address:
City
State
Zip Code
Cell Phone Number
Citizenship
I will be living on campus at HPU:

Campus Attending:
Indicate semester you plan to enter:




Academic year for which you are applying:
Emergency Contact Name & Relationship:
Emergency Contact Phone:

Insurance Information:
Howard Payne University does not provide accident or health insurance.  It is the responsibility of each student to secure his/her medical insurance.
Do you have hospitalization insurance?

Name of Insurance Company
Emergency Contact Work Phone:
Policy Number:
Group Number:
Acknowledgement Statement

To improve the efficiency and effectiveness of the health care system, the Health Insurance Portability and Accountability Act (HIPAA) was designed in 1996 to establish national standards of privacy to protect health information.  HIPAA limits the use and release of individual, identifiable, health information, gives patients the right to access their medical records, restricts most disclosure of health information to the minimum needed for the intended purpose, and establishes safeguards regarding disclosure of records for certain public responsibilities, such as public health, research, and law enforcement.  Improper use or disclosures of patient information under this rule are subject to criminal and civil sanctions. 

I have read and acknowledge the Final Statement and I give authorization for release/disclosure of my health information as deemed necessary per Howard Payne University unless revoked in writing.  If I feel my rights have been violated, I will contact the Assistant Vice President for Business and Human Resources at (325) 649-8012, Packer Administration Bldg. room 210. 


I acknowledge completing this worksheet, I/we certify that all parts of this form have been read and the information provided is true and correct.
Add initials for Student Acknowledgment:
Add Parent/Guardian initials ONLY if Student is >18 years of age:

About the Meningococcal Vaccination Requirement:
According to Texas law, on and after January 1, 2012, all first-time students, including transfer students, must present a certificate to the institution demonstrating they have been vaccinated against bacterial meningitis. A student may be exempt from the requirement if he or she presents a physician’s certificate indicating the vaccination would injure the health of the student or if he or she signs an affidavit declining the vaccination due to reasons of conscience including religious belief.  The latter provision does not apply during a public health emergency, terrorist attack, hostile military or paramilitary action or extraordinary law enforcement emergency. The bill exempts a student who is enrolled only in online or other distance education courses or who is 30 years of age or older. New and former HPU students to whom this requirement applies will not be permitted to schedule classes until compliance with this law is demonstrated by submitting the necessary paperwork (i.e., shot record, state affidavit, or physician's certificate). The vaccination or a booster must have been received within five years of the student's first day of classes.

 Class Scheduling will be blocked until proof is received.

Required Immunizations: 
     Please make sure that all doses that have been received are submitted on a verified Shot Record 
                Via Fax to (325) 649-8905; 
                Via Email to jskaggs@hputx.edu;
                Via the Shot Records Upload Tool on the Forms page; OR   
                Via Mail to HPU 1000 Fisk St Brownwood TX  76801   

•             Tetanus/Diphtheria (DPT, DTaP, DT,Td) – Required every 10 years
•             Polio
•             Hepatitis B
•             MMR
•             Meningococcal – MCV4 or MPSV (Booster required if initial dose was received > 5 years ago) AFTER January 1, 2012, shot record REQUIRED for ALL incoming students (or former students who stopped out) prior to class scheduling.
•             Varicella (Chicken Pox) Please provide Month & Year if you had the illness.
•             TB Skin Test – If you have been outside the US in the past 12 months

Any other vaccines that have been received (HPV, HepA, Hib, etc.) should also be included.


Student Personal History
Allergies to Medications: Use Ctrl or Shift keys to multi-select.
Food Allergies: Use Ctrl or Shift keys to multi-select.
Have you had: (Use Control or Shift Key to select multiple) Use Ctrl or Shift keys to multi-select.
If you have had the Chicken Pox, please list Month & Year of illness. If you have NOT had Chicken Pox or the Vaccination, please enter N/A.
Has your physical activity been restricted during the past five years?

Have you had difficulty with school, studies, or teachers?

Have you received treatment or counseling for a nervous condition, personality, and/or character disorder or emotional problem?

Have you had any illness or injury or been hospitalized other than already noted?

Have you been rejected for or discharged from military service because of physical, emotional, or other reasons?

*If you answered yes to any question in this section, please explain.
Prescription medications taken on a regular basis. State medication, dosage, how often, & reason.

Family History
Have any Relatives had: Use Ctrl or Shift keys to multi-select.
State relationship to any diseases selected above.
Father's Age:
Father's Occupation:
Father's State of Health:

If Father deceased, Cause of Death:
If Father deceased, Age at Death
Mother's Age:
Mother's Occupation:
Mother's State of Health:

If Mother deceased, Cause of Death:
If Mother deceased, Age at Death
List Brother(s) (Name, Age, State of Health & if deceased list cause. NA if not applicable)
List Sister(s) (Name, Age, State of Health & if deceased list cause. NA if not applicable)