First year student letter, physical, and immunization forms
Student Health CenterGETTSYBURG COLLEGE300 N. Washington StreetGettysburg, PA 17325Phone: 717-337-6970. Fax: 717-337-6978.Patient Portal Website:?? 2020Dear First Year Student,Welcome to Gettysburg College! You must read and comply with the Gettysburg College health requirements in order to move on to campus, attend class, and participate in intercollegiate athletics. Medical information is kept confidential for use by the Health and Counseling Services and Gettysburg College’s Athletics Department (if you are an athlete).Gettysburg College’s Health and Counseling Services relies on an Electronic Health Record (EHR) called Medicat. One of the many features of Medicat is its Patient Portal which will provide a secure entry point for you to find all the necessary forms that you will need to complete and instructions on what you will need to do based on whether you are an Athlete or a Non-Athlete. The following matrix outlines the items needed to be completed in order to comply with the college’s health requirements policy and can be found on your Gettysburg College Student Patient Portal. To Login to your Patient Portal, go to the website as noted above and log in using your Gettysburg College Network User ID and password that has been provided to you via separate communications. Once you are logged in, you will find all of the items you need to complete to be in compliance prior to your arrival on campus in August under the “To Do List” along with any specific instructions on exactly what you need to do.FORMSNON-ATHLETE STUDENTSATHLETE STUDENTSINSTRUCTIONSPHYSICAL EXAM FORM PREFERRED but not requiredREQUIREDSee Additional Items to Note belowPRINT FORM found on Medicat Patient Portal (MPP) and take to your Medical Provider to be completed. UPLOADthe Completed Form via your MPP UPLOAD feature to your patient record.IMMUNIZATION FORMREQUIREDREQUIREDPRINT FORM found on MPP and take to your Medical Provider to be completed. Prior to uploading the completed Immunization Form, ENTER THE DATA via the Immunizations Item on your MPP. Once data is entered, then UPLOAD the form for validation/verification.HEALTH HISTORY & MENTAL HEALTH HISTORY FORMSREQUIRED forFY DASHBOARDGreen CheckmarkREQUIRED forFY DASHBOARDGreen CheckmarkThis ONLINE FORM is available to complete via your Student Patient Portal under To Do List – Forms – First Year Required Forms ALL THE ABOVE FORM NEEDS TO COMPLETED AND UPLOADED BY JUNE 30, 2020ITEMS TO NOTE:If you are a Non-Athlete and choose to submit a physical exam by your home health care provider, it must have been done after May 1, 2019 and returned to us by June 30, 2020 unless you are an NCAA athlete – see note below.? NCAA ATHLETES PLEASE NOTE: Intercollegiate athletes' physicals must be done within six months of play - no sooner than May 1, 2020. Physicals done before that date will not satisfy NCAA regulations and will stop your ability to participate.? Athletes and potential athletes please send us any medical records, testing reports, echocardiogram reports, clearances or specific releases to participate in sports from orthopedists, cardiologists or surgeons for cardiac conditions, chronic medical conditions, illnesses or injuries, especially orthopedic related, or any surgery you may have had. YOU WILL NOT BE ALLOWED TO TRY OUT OR PRACTICE WITHOUT THESE CLEARANCES.Class registration and participation in intercollegiate sports will be in jeopardy until all medical information is completed, received and reviewed by the Student Health Services. Please do not upload/return the physician forms until you have reviewed them and all the information requested is filled in. Do not depend upon your health care provider's office to return the forms for you. It is your responsibility.The Student Health and Counseling Services welcome the Class of 2024 to our campus community. For further information about Health and Counseling Services, please visit the College website. You may also contact the Student Health Service at (717) 337-6970 or the Counseling Service for counseling/psychological questions or concerns at (717) 337-6960, Monday through Friday from 8:30am to 4:30pm.Judith Williams, CRNPKathy Bradley, Ph.D. Licensed PsychologistMedical DirectorExecutive Director, Health & Counseling CenterGettysburg College Health ServiceAssociate Dean of College LifeStudent Health CenterGETTSYBURG COLLEGE300 N. Washington StreetGettysburg, PA 17325Phone: 717-337-6970. Fax: 717-337-6978.Students (non-athlete) complete form after 5/1/19 *NCAA Athletes or potential athletes complete form after 5/1/20To examining provider: Please complete this form. This student has been accepted. The information supplied will not affect his/her status. It will be used only as a background for providing health care. This information is strictly for the use of the Health/Counseling Services and will not be released without student consent.I. Student InformationFirst name: FORMTEXT ?????Middle name: FORMTEXT ?????Last name: FORMTEXT ?????Gender: FORMTEXT ?????II. Health InformationHeight (inches): FORMTEXT ?????Weight (pounds): FORMTEXT ?????BMI: FORMTEXT ?????Blood pressure: FORMTEXT ?????Pulse: FORMTEXT ?????Athletes (recommended):Hemoglobin and hematocrit: FORMTEXT ?????Ferritin: FORMTEXT ?????Acuity: FORMCHECKBOX with correction FORMCHECKBOX without correctionRight: 20/ FORMTEXT ?????Left: 20/ FORMTEXT ?????III. Tuberculosis ScreeningMust check either low or high riskLow Risk: FORMCHECKBOX High Risk: FORMCHECKBOX Date of testing: FORMTEXT ????? Signature of Provider Testing: FORMTEXT ?????Date of reading: FORMTEXT ????? FORMCHECKBOX Negative FORMTEXT ????? mm FORMCHECKBOX Positive FORMTEXT ????? mmSignature of provider reading test: FORMTEXT ?????If test is positive: QuantiFERON Gold Test Date: FORMTEXT ?????Results: FORMCHECKBOX Negative FORMCHECKBOX Positive Please attach resultsAny treatment: FORMTEXT ?????Date of treatment: FORMTEXT ?????Chest X-ray: Date: FORMTEXT ?????Result: FORMTEXT ?????INH Treatment: Date: FORMTEXT ?????IV. Health AbnormalitiesAre there any abnormalities of the following systems?SystemNoYesDescribe FullyHEENT FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Respiratory FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Cardiovascular FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Gastrointestinal FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Genitourinary (inc. hernia) FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Musculoskeletal FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Metabolic/Endocrine FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Neuropsychiatric FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Skin FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????1. Is there loss or seriously impaired function of any organ? Yes: FORMCHECKBOX No: FORMCHECKBOX 2. Does student have physical appearance of Marfan’s syndrome?Yes: FORMCHECKBOX No: FORMCHECKBOX 3. Does the student participate in an intercollegiate sport?Yes: FORMCHECKBOX No: FORMCHECKBOX Which sport does the student participate in? FORMTEXT ?????4. On the basis of this examination, I find this student medically suitable to participate in intercollegiate sport activity at Gettysburg College.Yes: FORMCHECKBOX No: FORMCHECKBOX 5. Do you have any recommendations regarding the care of the student? Yes: FORMCHECKBOX No: FORMCHECKBOX Explain your recommendations: FORMTEXT ?????6. Is this patient now under treatment for any medical or emotional condition?Yes: FORMCHECKBOX No: FORMCHECKBOX Explain: FORMTEXT ?????V. Provider AuthorizationLast name: FORMTEXT ?????Address: FORMTEXT ?????Telephone: FORMTEXT ?????Fax: FORMTEXT ?????Provider’s Signature: FORMTEXT ?????Date: FORMTEXT ?????VI. StudentPlease upload this form along with your immunization record to the Gettysburg Student Patient Portal: Health CenterGETTSYBURG COLLEGE300 N. Washington StreetGettysburg, PA 17325Phone: 717-337-6970. Fax: 717-337-6978.Immunization Record – To Be Completed By Physician/HCP OfficeI. Student InformationFirst name: FORMTEXT ?????Middle name: FORMTEXT ?????Last name: FORMTEXT ?????Date of Birth: FORMTEXT ?????Required Immunizations1st Dose2nd Dose3rd DoseHepatitis B A 3-shot series is required. Blood test showing immunity is acceptable.Attach/upload copy of testing. FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????MMR (Measles/Mumps/Rubella) Two (2) doses after age 12 months given at least 28 days apart. Blood test indicating immunity is acceptable. Attach/upload copy of testing. FORMTEXT ????? FORMTEXT ?????Meningitis - Serogroup A,C,Y, W135Menactra, Menveo, Menomune FORMTEXT ????? FORMTEXT ?????Meningitis - Serogroup B Bexero or Trumenba FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Polio (OPV or IPV)Provide completed series date FORMTEXT ?????Tdap (Tetanus/Diphtheria/Pertussis) Vaccine (within 10 years) FORMTEXT ?????Varicella (Chicken Pox) *Two doses RequiredBlood test indicating immunity is acceptable. Attach/upload copy of testing. FORMTEXT ????? FORMTEXT ?????OR History of Varicella Disease FORMTEXT ?????II. Highly Recommended Vaccines (Not Required)1st Dose Date2nd Dose Date3rd Dose DateHepatitis A FORMTEXT ????? FORMTEXT ?????HPV (Human Papillomavirus Vaccine) FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????III. Provider AuthorizationPhysician/HCP Name: FORMTEXT ?????Signature: FORMTEXT ?????Date: FORMTEXT ?????Address or stamp: FORMTEXT ?????Telephone: FORMTEXT ?????Fax: FORMTEXT ?????NOTE TO STUDENT:? To comply with the immunization requirement, you will need to go to your Medicat Patient Portal, “To Do List – Immunizations” and enter the dates of all your immunizations.? Upon completion of entering your data, you MUST UPLOAD a copy of your immunization record via the UPLOAD feature to validate your entries. Patient Portal Website:?? ................
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