The College of St. Scholastica Office of Student Affairs

The College of St. Scholastica

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Medical History Information

To waive Student Medical Insurance please log into your Banner Web account. Click on Personal Information, then Answer a Survey and complete the Student Health Insurance Waiver Survey.

Please note that new students must fill out the required Medical History Information on this page.

To all students/parents: Each student entering The College of St. Scholastica is required to have the following medical history on file. The information will be kept in Student Health Services and will not be released without knowledge and consent. This correlation of past medical history, immunizations, and insurance will serve as a basis for any medical care received while attending The College of St. Scholastica.

All fields on this form are required.

Personal Information

Male Female

First Name:

Student ID Number:

Middle Name:

Date of Birth:

Last Name:

Maiden Name:

(if applicable)

Local Address

If you are unsure what your local address is going to be, please leave it as the listed default.

Permanent Address

Local Address:

Permanent Address:

City:

State:

Zip:

Phone:

Cell Phone:

Class status:

Freshman Sophomore Junior Senior Graduate

Emergency Contact Information

I authorize a member of the CSS Staff/Student Life Staff to contact the following person (e.g. parent, guardian, relative, doctor) in the case of an emergency.

Name:

Relationship:

Address:

City:

State:

Zip:

Home Phone:

Work Phone:

I do not authorize the contacting of anyone.

Family History

	Yes	No	Relative with condition	If yes, please describe
High Blood Pressure
Heart Disease
Stroke
Cancer
Anemia
Asthma
Epilepsy/Seizures
Stomach Trouble
Kidney Disease
Diabetes
Tuberculosis
Chemical Dependence
Mental Illness/Depression/Anxiety
Other:	(Please describe)

Personal History

Have you had?	Yes	No	If yes, please describe
Medication allergies
Eye/visual impairment
High cholesterol
Food allergies
Ear/hearing impairment
Kidney/bladder problems
Environmental allergies
Nose/throat trouble
Stomach/intestinal trouble
Chicken pox
Thyroid trouble
Joint/bone disease, injury
Mononucleosis
Diabetes
Back problem/injury
Hepatitis/jaundice
Lung/respiratory trouble
Eating issues: Anorexia/bulimia/over-eating
Cancer/tumor
Asthma/hay fever
Anxiety
Head injury
Heart problems
Depression
Headaches: Frequent/severe
Dizziness/fainting spells
Surgeries
Insomnia
Chest pain
Hospitalizations
Seizure/epilepsy
High blood pressure
Women: menstrual problems

Medications

Are you currently taking prescription/nonprescription medications?

Yes No

If yes, please describe the medications and dosage:

Do you take vitamins, minerals, herbal/natural products, supplements?

Yes No

If yes, please describe the supplements and dosage:

Health Habits

Do you use tobacco (smoke or chew)?

Yes No

Do you use alcohol?

Yes No

Do you use recreational drugs?

Yes No

Do you use caffeine?

Yes No

Do you wear seat belts?

Yes No

Do you exercise?

Yes No

Immunization Requirements

Minnesota Law (M.S. 135A.14) require that all students born in 1957 or later and:

Enrolled in more than one class;
Enrolled in only one class and housed on campus

Provide a statement with the month and year of immunization against each of the diseases specified below (certain exemptions listed below). This section of the Health History form is designed to provide the school with the information required by the law and will be available for the review by the Minnesota Department of Health and the local community health board.

If you wish to file an exemption to any of the required immunizations, you must print and complete this form.

Tetanus-Diphtheria (Td) booster shot must be within the last 10 years

Month:

Year:

M.M.R. (Measles, Mumps, Rubella) 1 dose required, 2 recommended (after 1 year of age)

Month:

Year:

M.M.R. (Measles, Mumps, Rubella) 2nd dose

Month:

Year:

The following are not required, but are strongly recommended.

Hepatitis B 1. 2. 3.

Menomune (meningitis):

Tuberculosis Screening¹

1.	Does the student have signs or symptons of active tuberculosis disease?	Yes No
2.	Is the student a member of a high-risk group or is the student entering the health professions?²	Yes No
3.	Tuberculin Skin Test
	Date Given: // (mm/dd/yy) Date Read: //(mm/dd/yy)
	Result: (Record actual mm of induration, transverse diameter; if no induration, write "0")
	Interpretation (based on mm of induration as well as risk factors): Positive Negative
4.	Chest x-ray (required if tuberculin skin test is positive) result: Normal Abnormal
	Date of chest x-ray: // (mm/dd/yy)

By clicking "Submit", I testify that to the best of my knowledge the information contained in this form is complete and accurate.

Medical History Information

Local Address

Permanent Address

Yes

No

Relative with condition

If yes, please describe

Have you had?

Yes

No

If yes, please describe