2/12/2019

Student Health Services |305 Estill Street Berea, KY 40403| Phone: (859) 985-1415

Welcome to Berea College! We look forward to being your health and wellness partner during your time at Berea!

Student Health Services offers a variety of FREE* medical and dental services to students including:

• Treatment of Acute Illnesses (strep throat, flu, etc.)

• Preventative Health Care

• Treatment of Minor Injuries

• Management of Chronic Conditions (blood pressure monitoring, asthma, diabetes, etc.)

• Preventative Dental Care (cleanings, check-ups/exams, etc.)

• Fillings

Our clinic is located on campus and offers evening and Saturday hours to accommodate student schedules.

Appointments can be scheduled by calling (859) 985-1415.

Berea College requires that specific medical information be on file for each incoming student prior to his or her arrival

on campus. Please know that all information submitted will go to both Berea College and White House Clinics.

These requirements include the following:

• Completed Health History Form

• Tuberculosis Screening Form

• Documentation of Required Immunizations

• Copy of Insurance Card (if covered)

Enclosed please find the health history and tuberculosis screening forms as well as a list of the required immunizations.

Your immunization records can be obtained from your physician, health department, or previous school. Your middle or high school will almost always have records/documentation of the required immunizations.

You are encouraged to update immunizations before coming to campus. Please consider the recommended

vaccinations when you are updating the required ones. Immunizations covered by insurance now, may not be covered later when you plan to study abroad or participate in internships. It may be costly to receive the immunizations later.

Students who plan to continue treatment for ADHD with Health Services will need to provide an assessment confirming the diagnosis from Psychiatrist, Psychologist or other Mental Health Provider. Date of assessment must be within 24

months.

Please mail this completed packet back to Student Health Services in the enclosed envelope. You may also email the

above information to studenthealth@whitehouseclinics.com. It is important that this information is received by

June 7, 2019. Please send all information together. Failure to supply the required information may result in delayed dormitory assignments and inability to confirm class registration.

If you have any questions or concerns please contact Jennie Horn, at Berea Primary Care (859) 985-1415, extension

3007. Thank you for your prompt attention to this important matter.

*Student Health Services are covered by the Health Fee included in each student’s Term Bill.

2/12/2019

Student Health Services |305 Estill Street Berea, KY 40403| Phone: (859) 985-1415

Immunization Requirements All students entering Berea College must demonstrate completion of required immunizations unless they have been

granted prior religious exemption*.

Required Immunizations include:

1. A series of (2) measles, mumps, and rubella (MMR) vaccinations.a. One vaccination after your first birthday.b. The second vaccination must be a minimum of one month later.

2. A primary series of tetanus-diphtheria-pertussis (Tdap) immunization followed by a tetanus. booster (Td or Tdap) within the last 10 years.

3. A primary series of polio (IPV) immunizations.4. Meningococcal Immunization (one after age 16).

Varicella, Hepatitis A, and Hepatitis B are highly recommended but not required. Please be aware that insurance coverage for immunizations changes around ages 18 – 21. Vaccines covered now may not be covered later when they are needed for study abroad programs or internships.

If you do not have all the required immunizations, you must obtain them before coming to Berea College. If you have

any special circumstances that make it difficult to provide immunization records or you need assistance in obtaining the

vaccines, contact Jennie Horn at Student Health Services by calling (859) 985-1415, extension 3007 or email

studenthealth@whitehouseclinics.com. Failure to supply proof of the required immunization may result in delayed

dormitory assignments and inability to confirm class registration.

Checklist of Information to Return by June 7, 2019. Please submit all materials together!

Email to studenthealth@whitehouseclinics.com or fax to (859) 986-6752.

Mail to White House Clinics, Student Health Services, 305 Estill Street, Berea, KY 40403.

___ Completed Health History ___ Copy of Insurance Card (Front & Back)

___ Tuberculosis Risk Assessment ___ Proof of Required Immunizations

___ Results of TB Skin Test if Answered Yes to Questions 4-12

___ ADHD Assessment (if applicable)**

*Those requesting religious exemption should contact Student Health Services by phone or e-mail to obtain the required documentation form.

Religious exemption status may affect ability to participate in certain international travel opportunities offered by the College. Immunization status

is reviewed prior to clearance for all college-sponsored travel and disease risk for un-immunized travelers is of utmost concern.

**The Assessment must be provided from Psychiatrist, Psychologist or other Mental Health Provider. (Date of assessment must be within 24

months).

Health History FormDate: _____________________

Family Physician: ___________________________________________ Phone: ___________________________

Address:____________________________________ City: _______________ State: ___________ Zip: ____________

Name:_______________________________________________________ Date of Birth: ______/________/______

Street:____________________________________ City: _______________ State: ___________ Zip: ______________

Phone: ___________________ Sex: Male Female Other:________________ Marital Status: M S W D

Appendix Removed

Back Surgery

Bladder Surgery

Cataract

C Section

Ear Tubes

Heart Catheterization

Gallbladder Removal

Heart Bypass

Surgical History YearHernia Repair (type:_____________________)

Hysterectomy: Partial or Complete

Orthopedic Surgery (bones)

Orthodontic Surgery (teeth)

Tonsils Removed

Tubal Ligation

Vasectomy

Other:

Other:

Other:

Year

Cancer: Type_____________

High Cholesterol

Diabetes Mellitus

Heart Disease

Hypertension

Mental Illness

Stroke

Substance Abuse/Alcoholism

Other: (specify:_______________)

Family History: indicate which family members have had the following None Mother Father Sister Brother Other

Name:_______________________________ Relationship: _____________________ Phone: ____________________

Address:__________________________________ City: ________________ State: ___________ Zip: _____________

Patient Information

Emergency Contact

None

Name of Medication Strength (mg) How Often Reason for Medication

Current Medications *If you need more lines, please print a second form.

NoneAllergies

Acid Reflux

ADHD

Anxiety

Asthma

Bipolar Disorder

Blood Clot (DVT/PE)

Cancer

Chronic Pain

COPD

Past Medical History Yes No

Coronary Artery Disease

Crohn’s Dis/Ulcerative Colitis

High Blood Pressure

High Cholesterol

Enlarged Prostate

Heart Attack

Heart Valve Problem

Hepatitis

Hemophilia (Free Bleeder)

Yes NoDepression

Diabetes

Kidney Disease

HIV/AIDS

Seizure Disorder

Stroke

Seasonal Allergies

Substance Abuse/Alcoholism

Thyroid Problem

Tuberculosis

Other:

Yes NoMigraines

Peripheral Artery Disease

Rheumatoid Disease

Do you have children? Yes No Number of Children____ Do you have custody? Yes No

Job Occupation _____________________________________________________________________________ Retired

Disabled If disabled, please list reason:_______________________________________________________

Tobacco Use None Quit (date)___________ Still use: Cigarettes Smokeless/Chew Cigars Pipe

Check the amount of tobacco you use(d) each day. 1/2 pack/can 1 pack/can More

How many years did/have you smoked? ________ 2 packs/cans

Alchol Use None (A drink is 1 shot of liquor, 1 glass of wine, or 1 bottle/can of beer.)

Less than 1 drink/month 1-15 drinks/month 4-14 drinks/week More than 2 drinks/day

Drug Use Yes No Quit (date)_______ If yes, what do you use regularly?_____________________________________

HIV/AIDS Screening Yes No If yes, where and when?_____________________________________________________

Social History

Health History Form(continued)

Do you wear seatbelts? Always Sometimes Never

Have you seen a dentist in the past year? Yes No

Date of your last colonoscopy: ________ Date of your last pneumonia shot: ________

Date of your last tetanus shot: ________ Date of your last shingles shot: ________

Date of your last flu shot: ________ Date of your last eye exam: ________

Health Maintenance

Date of your last mammogram: __________ Date of your last pap smear: __________

Number of pregnancies? __________

Women ONLY:

Do you have an advanced directive or a living will? Yes No

If yes, please give a copy to front desk.

If no, would you like more information? Yes No

Advanced Directives/Living Wills

Although most primary care services are provided at no cost by Student Health Services, the College requires all studentsto maintain insurance in case the student’s condition requires additional diagnostic procedures or treatment. Students caneither choose to be covered by a family plan, purchase a plan on healthcare.gov, or purchase the safety net plan offered byBerea College. Out of state insurances should be verified that coverage extends to Kentucky. Students who need topurchase coverage through Berea College should respond to emails sent by Financial Aid early in the Fall Term.Please note: the Berea College safety net plan does not meet minimum required coverage of the Affordable Care Act.

I do not have insurance coverage. I have state Medicaid coverage. If yes, what state?_________________

I have private insurance. Please provide the below information.

Company Name:__________________________________________________________________ Phone: _______________________Address: ________________________________ City:_______________________ State: ___________ Zip:___________________Policy Holder: ______________________________________________________ Relationship to Student: _______________________Coverage to Age: ______________________ Policy #: __________________________ Group: ______________________________

Health Insurance Information (Required for all Students)

Students who will be under 18 years of age at the time of the entrance to Berea College MUST have the following consentsigned by a parent or legal guardian.

I hereby give my permission to White House Clinics for the evaluation and treatment of the medical and dental conditionsof my minor dependent. This includes the administartions of vaccinations or other procedures as determined by the treatingprovider. Furthermore, I authorize my minor dependent to seek care and treatment without a parent or guardian present.

Consent for Treatment (Only Students Less Than 18 Years Old)

Signature of parent or guardian Date

IMMUNIZATION WAIVER REQUEST

Student Health ServicesBerea Primary Care

St. Joseph Hospital BereaBerea, KY 40403

Phone: (859) 985.1415Fax: (859) 986-0189

Name: _______________________________________ ________________________________________ ____

Address:________________________________________________________________________________________

Country: ________________________________________________________________________________________

Date of Birth: _____/_____/_____ Social Security # ______-______-______ Phone:_________________________

Choose one of the following:

_____ I request exemp�on from required immuniza�on(s) for the following medical reasons:

_____ I request exemp�on from immuniza�on(s) on the basis of the following sincere and genuine religious beliefs:

I understand that in the event of an epidemic, I may be required to receive the immuniza�on or leave Berea College un�l all disease risk is eradicated. I also understand that par�cipa�on in interna�onal College sponsored study/travel opportuni�es may be denied for non-immunized students entering the College claiming exemp�on from required medical immuniza�ons or refusing recommended immuniza�on for travel.

Students par�cipa�ng in interna�onal study/travel opportuni�es are required to receive from Student Health Services or a recognized travel authority such as the Center for Disease Control or similar body all immuniza�onsrecommended for travel to a par�cular region. Excep�on to this policy will be made only for a student who has an approved immuniza�on waiver on file with the College from the �me of ini�al enrollment. However, such waiver may affect ability to par�cipate in certain interna�onal travel opportuni�es. The College retains the right to deny approval for travel for which academic credit and/or funding is being provided by the College should it be felt that the health of the non-immunized student or other community members might be jeopardized.

All traveling students reques�ng exemp�on from such travel recommenda�ons must receive counseling from Student Health Services concerning the risks they are assuming, must sign a special waiver form before every interna�onal trip, and must receive approval from Student Health Services.

Students under 18 years of age must also have the signature of a parent or legal guardian and a witness not related to the signer or applicant.

_______________________________________________ ______________________________________________

_______________________________________________ _______________________________________________

Last First MI

Street City State Zip

Signature of Student Witness (not a relative)

Signature of Parent or Guardian Date

Revised 2/12/2019