Student Health Center

Special Programs Building

28 Westhampton Way
University of Richmond, VA 23173
Phone: 804-289-8064
wellness.richmond.edu

Student Name: ______________________

UR ID: ______________________________

2015-2016 HEALTH HISTORY RECORD

(Student Completes)
Deadline All Students: June 12, 2015
(Spring Semester Transfers - January 4, 2016)

Students with incomplete forms are blocked from housing on move-in day.
MAIL THE COMPLETED FORM TO: Student Health Center, Special Programs Building, 28 Westhampton Way,
University of Richmond, VA 23173
RECORDS RECEIVED BY SCAN OR FAX WILL NOT BE ACCEPTED.
Name _____________________________________________________________________________________________
Last

First

Date of Birth ____/___/____

Middle

Social Security #________________________

UR Student ID # _____________________

Permanent Address __________________________________________________________________________________

Street

City

State /Country

Zip Code

Country of Birth ____________________ Email ___________________________________________________________

(Please print clearly)

Home Phone ___________________________ Students Cell ________________________________________________

Undergraduate _____

Law School _____

School of Continuing Studies _____

Incoming Class Status: 1st yr ___, 2nd yr. ____, 3rd yr. ___, 4th yr. ___

NCAA ATHLETE ____ SPORT ________

Although highly recommended, the University of Richmond does not require students to be covered by a medical insurance policy.
Is student covered by a medical insurance policy? Please circle: Yes or No

MEDICAL HISTORY
Yes No
ADD/ADHD
Allergies (annual/seasonal)
Anemia
Asthma/Exercise-Induced Asthma
Bone/Joint Disorder
Cancer
Chickenpox
Circulatory Problems/Blood Clots
Convulsions/Seizures/Epilepsy

Yes No
Diabetes
Eating Disorders
Mental Health Disorder
Gastrointestinal Problems
Gynecological Problems
Frequent Headaches
Heart Disease
Hepatitis/Liver Disease
HIV

Yes No
Kidney/Urinary Problems
Mononucleosis
Rheumatic Fever
Tuberculosis
Sexually Transmitted Disease
High Blood Pressure
Frequent Throat Infections
Frequent Ear Infections
Other Explain Below

Remarks or Additional Information: _________________________________________________________________________________

______________________________________________________________________________________________________________
Allergies: medication/foods, etc (include reaction): ___________________________________________________________________________
Significant illness/hospitalization/surgery (include dates):

____________________________________________________________

______________________________________________________________________________________________________________
History of psychiatric/psychological disorder (include dates):
EMERGENCY CONTACT :

____________________________________________________________

Name:____________________________ Relationship: ________________________________________

Phone (list all): _______________________________________

Address: _________________________________________________

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Student Health Center

Special Programs Building
28 Westhampton Way
University of Richmond, VA 23173

Student Name:__________________
UR ID:___________________________
Student Cell Phone:_______________

TUBERCULOSIS RISK ASSESSMENT (TBRA)

Student Completes within 6 months of entrance to University

1. Have you ever had a positive tuberculosis (TB) test?

YES

NO

2. Were you born in one of the following countries?

YES
NO
Africa, Asia, Central America, Cuba, Dominican Republic, Eastern Europe, Haiti, India & other Indian
subcontinent nations, Middle East (except Egypt, Isreal, Jordan, Lebanon, Saudi Arabia, UAE),
Portugal, South America, South Pacific (except Australia & New Zealand).
3. Within the past 5 years, have you traveled to OR lived in any
YES
NO
of the following countries for more than one month?
Africa, Asia, Central America, Cuba, Dominican Republic, Eastern Europe, Haiti, India, & other Indian
subcontinent nations, Middle East (except Egypt, Isreal, Jordan, Lebanon, Saudi Arabia, UAE),
Portugal, South America, South Pacific (except Australia & New Zealand).
4. Do you have any of the following signs or symptoms of active TB disease?
YES
NO
Unexplained fever/chills for more than 1 week unexplained fatigue unexplained weight loss
night sweats cough with bloody sputum persistent cough of unknown etiology for more than 3 weeks.
5. Do any of the following situations apply to you?
YES
NO
Close contact with a person known or suspected to have TB use of any illegal injectable drug
at risk for Human Immunodeficiency Virus (HIV) infection history of solid organ transplant (kidney, heart, liver)
history of silicosis, diabetes, renal disease, blood disorders or cancer, gastrectomy
jejunoilieal bypass chronic malabsorptive condition low body weight (10% or more below ideal)
volunteered, resided, or worked in a healthcare facility or congregate living setting (homeless shelter,
nursing home, or correctional facility) for longer than 1 month on immunosuppressive therapy, such as
prolonged corticosteroid therapy, chemotherapy on TNF-antagoinist medications (Humira, Embrel, Remicade)

IF YOU ANSWERED 'YES' TO ANY QUESTION ABOVE, TB TESTING IS REQUIRED

The Student Health Center (SHC) requires either the IGRA (Interferon Gamma Release Assay) Quantiferon Gold TB
test or the T-Spot TB test. PPD SKIN TESTS AND CHEST X-RAYS ARE NOT ACCEPTED IN LIEU OF THE IGRA.

Please select

one of the following options to complete your IGRA testing:

1.

Have the test done as soon as possible, prior to coming to the University. It may take several weeks for
the results, so do not delay testing. Submit a copy of the written report to the Student Health Center.

2.

Have the test done at the SHC during Orientation Week. The SHC will be open 8:30 am until 4:30 pm
Tuesday, August 18 through Friday, August 21. The charge for testing at the SHC is $75.00 which may be paid by
cash, check, SpiderCard, or placed on your Student Account.

3.

Students attending International Orientation: You will be scheduled for the test on Monday, August 17.
URs Office of International Education will provide information regarding your appointment time.

Student Signature:__________________________________________ Date: __________________

(or legal gaurdian if under age 18)

Page 2 of 4

Student Health Center

Special Programs Building
28 Westhampton Way
University of Richmond, VA 23173
Phone: 804-289-8064
Wellness.richmond.edu

Student Name:__________________
UR ID: _________________________
Date of Birth: ___________________
Student Cell Phone: ______________

2015-2016 IMMUNIZATION RECORD Due June, 12, 2015

TO BE COMPLETED AND SIGNED BY YOUR HEALTH CARE PROVIDER
If vaccination dates are unavailable it is necessary to repeat the
vaccine or submit laboratory evidence of immunity (titer).

Virginia State Law and the University of Richmond Require the Following Immunizations
1) MMR (Measles, Mumps, Rubella)

Dose #1 _____/____/____

Two doses live vaccine required at or after 12 months of age, at least one month apart

Dose #2 _____/____/____

Use ONLY If vaccinated separately:

Measles

Dose #1 ____/____/____

Rubella

Dose #1 ____/____/____

Dose #2 ____/____/_____

Mumps

Dose #1 ____/____/____

Dose #2 ____/____/_____

2) TETANUS/DIPHTHERIA/PERTUSSIS (Tdap) or TETANUS/DIPTHERIA This booster date: _____/____/____must be within last 10

years. If this date is older than 10 years, revaccinate and attach documentation.
3) MENINGOCOCCAL VACCINE (ACYW-135) This booster date: _____/____/____ must be after student turns 16. If vaccine given
prior to 16th birthday, either revaccinate & attach documentation or sign waiver see next page.
4) HEPATITIS B VACCINE

Dose #1 _____/____/____

(3 doses required)

Dose #2 _____/____/____
Dose #3 ____/____/____
(or sign waiver see next page)

5) POLIO VACCINE
Last dose date:_____/_____/___ must be after student turns 4. If last dose given prior to 4th
birthday, sign waiver see next page.

RECOMMENDED IMMUNIZATIONS
A. VARICELLA VACCINE- (STRONGLY RECOMMENDED)
Two doses of vaccine one month apart
OR History of Disease

Dose #1_____/____/____
Dose #2_____/____/____

____/____

B. HEPATITIS A VACCINE
2 doses vaccine given at 0, 6-12 months

Dose #1_____/____/____
Dose #2_____/____/____

C. HUMAN PAPILLOMAVIRUS VACCINE (HPV)

3 doses at 0, 2, and 6 month intervals

Dose #1_____/____/____
Dose #2_____/____/____
Dose #3_____/____/____

D. PNEUMOCOCCAL VACCINE (Type of Vaccine): PPSV23 ____ OR PCV13 ____

Dose #1 ____/____/____

Verified by :

Health Care Providers Signature

Name Printed
Address
Phone
Date

Page 3 of 4

WAIVER DOCUMENT

HEPATITIS B

Name: ____________________

HEPATITIS B is a serious infection of the liver caused by the Hepatitis B virus. The Hepatitis B virus (HBV) may

cause lifelong infection, cirrhosis of the liver, liver cancer, liver failure and death. Hepatitis B is transmitted
through infected body fluids such as blood, semen, and vaginal secretions; infection may occur through mucous
membranes and broken skin. Most commonly, Hepatitis B is transmitted by sexual contact. It may also be spread
by exposure to blood through contact sports, repeatedly sharing an infected persons razor, toothbrush, or
earrings, travel to a high-risk area, use of illicit injectable drugs or through contaminated needles use for tattooing
or piercing. The Hepatitis B vaccine is safe and effective. The vaccine is generally a series of three doses given over
a period of 6 months, although the series never has to be re-started if the schedule is interrupted.
HEPATITIS B VACCINE WAIVER
I have reviewed the information provided on the risks associated with Hepatitis B disease, and the effectiveness of
any vaccine against Hepatitis B disease and I choose not to be vaccinated at this time.

Print Students Name: ________________________________ Date: _______________ Student Signature: __________________________________

(or Legal Guardian if under 18)

MENINGITIS
MENINGOCOCCAL DISEASE is a potentially fatal bacterial infection caused by the organism Neisseria

meningitis. Although meningococcal disease is relatively rare, the initial flu-like symptoms may make diagnosis
difficult. The disease may lead to brain damage, vital organ failure, permanent disability or death. Studies indicate
college students living in residence halls, especially freshmen residents, are at increased risk of infection.
MENINGOCOCCAL VACCINE WAIVER

I have reviewed the information provided on the risks associated with Meningococcal disease, and the effectiveness of any vaccine
against Meningococcal disease and I choose not to be vaccinated at this time.
Print Students Name: _______________________________________Date:____________ Student Signature: _______________________________________________
(or Legal Guardian if under age 18)

POLIO
POLIO is a highly contagious disease caused by a virus. The virus affects the nervous system and one in two

hundred cases leads to irreversible paralysis. There is no cure for polio; it may only be prevented by vaccination.
Polio vaccination has eradicated the disease from the US, but polio remains endemic in Afghanistan, Pakistan and
Nigeria and outbreaks continue to occur in some regions and countries*(see listing below). The Student Health
Center abides by the recommendations from the Centers for Disease Control and Prevention (CDC) if you
have not been previously vaccinated.

UNITED STATES RESIDENTS

18 YEARS OF AGE OR OLDER: Polio vaccine is not necessary or recommended, UNLESS you have plans to travel
to one of the countries listed below*. Please sign the Polio Vaccine Waiver.
UNDER 18 YEARS OF AGE: You must be vaccinated. Please send documentation of polio vaccination to the Student
Health Center.
FOREIGN-BORN
If you were born or reside in a country listed below* which has a high incidence of polio, 3 doses of vaccine are
required. Appropriate vaccination consists of two doses separated by 1-2 months, and a third dose 6-12 months
(6-month minimal interval). Please send documentation to the Student Health Center. If you were born or reside in
a country not listed below* and choose not to complete your polio vaccinations, please sign the Polio Waiver.
*Countries

Republic.

with High Incidence of polio: Afghanistan, Ethiopia, Iraq, Nigeria, Pakistan, Somalia, & Syrian Arab

POLIO VACCINE WAIVER

I have reviewed the information provided on the risks associated with polio disease and the effectiveness of polio vaccination.
I choose not to be vaccinated at this time.
Print Students Name: ______________________________________________Date:_____________________Student Signature:___________________________________
(or Legal Guardian if under 18)

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