Resources and Programs > Health Form

Health Form

This health form must be completed by all students. Those students who do not have a completed health form on file in the Student Health and Wellness Office will have an administrative hold placed on their academic records.
Please answer all questions honestly and completely.
The information may be given to appropriate medical authorities in the event a student requires medical care. Information will not be released without the student's consent.
All student athletes in addition to this Health Form must complete a Preparticipation Physical Evaluation and mail this form to:
     Amy Heiby
     PO Box 308
     Notre Dame, IN 46556-0308

General Information

First Name*

Last Name*

Permanent Address*

City*

State/Prov*

Zip*

Country

Home Telephone

Date of Birth

Email Address*

Father Name

Father Home Phone

Father Work Phone

Mother Name

Mother Home Phone

Mother Work Phone

If you do not live with a parent, please indicate the name of your Guardian or Spouse:

Name

Relationship

Home Phone

Work Phone

Insurance Information

Please check with your insurance carrier to be sure coverage is extended to you as a student over the age of 18. Adequate insurance coverage is required. Student health insurance information is available at the Office of Student Affairs.

Name of Insurer

Policy Number

Insurance Holder

DOB of Insurance Holder

Address of Insurance

Phone of Insurance

Health Information

Height

Weight

Do you regularly take/use prescription drugs? If so, please list all medications:

If you are allergic to any medications, foods, or environmental conditions and if you take any allergy injections, please list:

Please state details of any medical conditions including diagnosis, age, duration, treatment, and outcome. If you have had any serious, chronic medical problems, please ask your physicianor surgeon to forward to Holy Cross College Office of Student Affairs a copy of consultation, reports, notes, labs, and/or letter summarizing your problem, including past and present treatments and recommendations for continuing care.

Medical conditions:

Primary Care Physician

Name of Clinic

Address

Phone Number

If you see a specialist, please have your physician provide a description of the condition, treatment, and list of medications and forward it to the Office of Student Affairs.

Consulting Specialist

Type of Specialty

Address

Phone Number

Immunization Information

Indiana State Law (IC20-12-71) requires that postsecondary students provide proof of vaccination against measles, mumps, rubella, tetanus, and diphtheria. Indiana State Law also requires that individuals be provided information, and indicate receipt by signature, on the risks associated with meningococcal disease and the availability and effectiveness of vaccination. Specific majors, classes, and activities may have additional health requirements. Requests for exemptions based on medical or religious reasons must be filed with the Office of Student Affairs.

REQUIRED FOR ALL STUDENTS AT HOLY CROSS COLLEGE

M.M.R. (Measles, Mumps, Rubella) (Two doses required.)
1. Dose 1 given at age 12-15 months or later

Date of Dose 1

2. Dose 2 given at age 4-6 years or later, and at least one month after first dose

Date of Dose 2

TETANUS-DIPHTHERIA (Primary series with DTaP or DTP and booster with Td in the last 10 years meets requirement.)

1. Have you had the primary series of four doses with DTaP or DTP?

YesNo

2. Have you had a Tetanus-Diphtheria (Td) booster within the last 10 years?

Date of Td booster

REQUIRED FOR STUDENTS WHO ARE NOT U.S. RESIDENTS OR CITIZENS

TUBERCULOSIS SCREENING (Mantoux)

Date Given

Date Read

Result: (Record actual mm of induration, transverse diameter; if no induration, write "0"

Interpretation (based on mm of induration as well as risk factors):

SignificantNon-significant

Chest x-ray (required if tuberculin skin test is significant) result:

NormalAbnormal

Date of chest x-ray

HIGHLY RECOMMENDED (OPTIONAL)

HEPATITIS B (Three doses of vaccine or two doses of adult vaccine in adolescents 11-15 years of age.)

1. Immunization (Hepatitis B)
OR
2. Immunization (Combined Hepatitis A and B Vaccine)

MENINGOCOCCAL VACCINE (Menomune)

Date of Vaccine

Please read important information about the Meningococcal disease and vaccine in THIS DOCUMENT.

Release Consent

I hereby state that my answers to all of the questions are accurate to the best of my knowledge. I give consent to release the information of this report to proper medical authorities in the event I require medical care. (If I am under the age of 18 when I begin at HCC, I have consent from my parent or legal guardian for release of information and for required medical care.)