Student Health Record Form Howard Payne UniversityStudent LifeStudent ResourcesHealth ServicesStudent Health Record Form Download the printable version of this form. All fields are required. Gender Male Female * Select State... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming * Citizenship United States Dual U.S. Citizen U.S. Permanent Resident Visa Other Citizenship I will be living on-campus Yes No * Campus Attending Brownwood El Paso New Braunfels * Semester you plan to enter Fall Spring May Term Summer I Summer II 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 Yes No 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 22 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) 649-8819; Via Email to email@example.com; Via the Shot Records Upload Tool on the Forms page; OR Via Mail to HPU 1000 Fisk St Brownwood TX 76801 Required immunizations include: * 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 before 16th birthday or > 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+Click to Select Multiple) No Known Allergies to Medications Penicillin Sulfa Codeine Aspirin Cortisone Iodine Other * Food Allergies (Use Ctrl+Click to Select Multiple) No known food allergies Yes * Have you had (Use Ctrl+Click to Select Multiple) None Scarlet Fever Measles German Measles Mumps Chicken Pox Malaria Gum or Tooth Trouble Sinusitis Eye Trouble Ear, Nose, Throat Trouble Appendectomy Tonsillectomy Hernia Repair Herpes Simplex 1 Herpes Simplex 2 Frequent Anxiety Frequent Depression Worry or Nervousness Recurrent Headaches Recurrent Colds Head Injury with Unconsciousness Hay Fever, Asthma Tuberculosis Shortness of Breath Migraine Headaches Diabetes Epilepsy Anemia Pain/Pressure in Chest Chronic Cough Heart Palpitations High/Low Blood Pressure Rheumatic Fever or Heart Murmurs Disease or Injury of Joints "Trick" Knee, Shoulder etc. Back Problems Tumor/Cancer/Cyst Jaundice Stomach or Intestinal Trouble Hepatitis B Anorexia/Bulimia Gallbladder Trouble or Gallstones Recurrent Diarrhea Ruptured Hernia Recent Gain/Loss of Weight Dizziness/Fainting Weakness, Paralysis Venereal Disease Albumen/Sugar in Urine Frequent Urination Alcohol/Drug Abuse Women Only: Menstrual Problems If you selected any of the conditions above, please use this space to elaborate. Enter N/A if not applicable. * If you have had 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? Yes No Have you had difficulty with school, studies or teachers? Yes No Have you received treatment or counseling for a nervous condition, personality and/or character disorder or emotional problem? Yes No Have you had any illness or injury or been hospitalized other than already noted? Yes No If you answered "yes" to any question in this section, please explain. Do you take any prescription medications on a regular basis? State medication, dosage, how often & reason. * Have any relatives had (Use Ctrl+Click to Select Multiple) No Known Disease Tuberculosis Diabetes Kidney Disease Heart Disease Arthritis Mental Illness Asthma/Hay Fever Epilepsy/Convulsions High Blood Pressure Cancer * State Your Relationship to Anyone with the Diseases Listed Above * Father's State of Health Alive and Well Deceased * Mother's State of Health Alive and Well Deceased * 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) 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.