Health Form

ALL students are required to provide the following information. It is kept confidential and maintained as a part of a student’s medical record in Health Services. Information cannot be released to anyone without express permission from the student concerned.

PERSONAL INFORMATION

What semester and year will you begin attending SDCC?
Are you a returning student to SDCC? If yes, what year/semester were you previously enrolled?	Yes No
Gender Male Female
Date of Birth (MM/DD/YY)
Name (Legal) Last
First
Middle
Address

City - State - Zip
- -
Personal Contact
Home Phone
Cell Phone
Email
Parent/Guardian Name
Address, City, State and Zip of Parent/Gaurdian if different from above:

INSURANCE INFORMATION & MEDICAL RELEASE

Emergency Contact
Name
Phone
Accident/Health Insurance Company

Group/Policy Number
Company Phone
Personal Physician
Physician's Phone
Address/City/State/Zip of Personal Physicial

PERMISSION FOR TREATMENT

In case of routine health examination, immunization, diagnostic procedure, treatment of illness and/or injuries, permission is hereby granted to treat the student named below at the Health Services Office at San Diego Christian College, and to make necessary referrals to private physicians and other community facilities as indicated.

By checking this box and typing my legal name below I hereby acknowledge use of my electronic signature and verify that all information is true and correct. Date:

Parent/Guardian - By checking this box and typing my name below I hereby acknowlege use of my elecgtronic signature, as required for students under 18.

Date:

PERSONAL HEALTH

Please rate the following:
General Health Excellent Good Poor
Eyesight Excellent Good Poor
Hearing Excellent Good Poor
Height ft in - Weight lbs
Previous Surgeries:

Previous Serious Injuries:


Do you have any physical limitations? Yes No
If yes, please explain:

Have you ever had a serious reaction to a bee sting? Yes No
If so, describe the reaction:

Are you currently under the care of a physicial for any health problems?
(e.g. diabetes, high blood pressure, depression, eating disorders, asthma, allergies) Yes No
If yes, please state the condition and treatment:

Are you currently using any medications on a regular basis? Yes No
If yes, please explain:

Are you allergic to any medications? Yes No
If yes, please list:

California law requires that all students read, respond to, and sign the following:
MENINGITIS INFORMATION

Meningococcal disease is caused by Neisseria Meningitidis bacteria. The two most common forms of meningococcal disease are meningitis, a bacterial infection of the fluid and covering of the spinal cord and brain; or septicemia, an infection of the bloodstream. It is relatively rare. Common symptoms include stiff neck, headache, fever, sensitivity to light, sleepiness, confusion, and seizures. It can lead to brain damage, disability, and death. College-aged students, particularly those living in residence halls, have a modestly increased risk of getting the disease. For this reason, the American College Health Association has adopted the guidelines set forth by the Advisory Committee of Immunization Practices. These guidelines encourage dissemination of information regarding this disease and vaccination availability to those who wish to reduce the risk of meningococcal disease. For more information visit the Department of Health Services for the State of CA website, www.dhs.ca.gov.

Check One:

I intend to receive the meningococcal vaccine from my family physician or public health center.
I have already received the meningococcal vaccine.
I do not intend to receive the meningococcal vaccine.

By checking this box and typing my legal name below I hereby acknowledge use of my electronic signature and verify that all information is true and correct. Date:

Immunizations are required by San Diego Christian College. They may be obtained through private physicians or local health departments. If you are opposed to immunizations due to religious or medical reasons, please attach supporting documentation to this form.

Prior to admission to the College, all students are REQUIRED to have:

TB Skin Test (Turberculosos) administered no earlier prior to arrival on campus.

Month Year

Positive
Negative

If positive, please provide evidence of negative chest x-ray or treatment plan.

Tetanus-Diptheria Booster required within the last 10 years

Month Year

MMR (Measles, Mumps, Rubella) 2 required

1st - Month Year (age 12-15 mo. or older)

2nd– Month Year (age 4-6 years or older)

SDCC and the American College Health Association strongly recommend
but do not require the following vaccines:

Hepatitus B Series, Hepatitus A Series, Meningococcal, Varicella, and Polio

Contact your physician for information.

By checking this box and typing my legal name below I hereby acknowledge use of my electronic signature and verify that all information is true and correct. Date:

Please inform Health Services regarding any major health changes during
your enrollment at SDCC. Questions can be directed to the College nurse at

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