Health History

Parents or Guardians
Height
Immunization Records

REQUIRED DOCUMENTATION: Please provide the necessary dates below. You must also submit documented proof of the following (completing this early will save you time in lines when you arrive):

  • Negative tuberculosis skin test (TST) within one year prior to admission. If the TB skin test is positive, you must show proof of having normal chest X-ray within one year prior to admission.
  • Current tetanus immunization within the past ten years.
  • Immunity to red measles (rubeola) and German Measles (Rubella). Each student born after 12/31/56 must show proof of two red measles (rubeola) vaccines after their first birthday or a blood test (titre) proving their immunity to the disease.

You can submit these documents by faxing (402.486.2564), emailing scans (studenthealth [at] ucollege [dot] edu) or mailing copies (3800 S. 48th Street; Lincoln, NE 68506).

Test must be within one year prior to admission (documentation required). If the test is positive, you must show proof of having normal chest X-ray within one year prior to admission.
Each student born after 12/31/56 must show proof of two red measles (rubeola) vaccines after their first birthday or a blood test (titre) proving their immunity to the disease.
Documented proof of current tetanus immunizations within the past ten years must be provided.
Personal Health Questions
Ear, Nose, and Throat
YesYes, less than 1 year agoNo
Trouble with hearing?
Severe difficulty breathing through your nose?
Frequent sore throats or colds?
Eyes
YesYes, less than 1 year agoNo
Need of eye glasses or contact lenses?
Loss of vision or damaged function in one or both of your eyes?
Dental
YesYes, less than 1 year agoNo
Gum or tooth trouble?
Respiratory
YesYes, less than 1 year agoNo
Loss of or damaged functioning of a lung?
Asthma?
Pneumonia?
Tuberculosis?
Cardiovascular
YesYes, less than 1 year agoNo
A heart murmur that the doctor said is serious?
High blood pressure?
Rheumatic fever?
Gastronintestinal
YesYes, less than 1 year agoNo
Consistent pain in the abdomen?
Frequent episodes of vomiting?
Trouble with gas, heartburn, sour stomache, bloating, or indigestion?
Stomach or duodenal ulcers?
Recurrent diarrhea?
Jaundice or Hepatitus
Any serious or disabling stomach or bowel problems?
Genito-Urinary
YesYes, less than 1 year agoNo
Damaged function of a kidney
Frequent infections in the kidney or bladder?
Sexually transmitted disease or infection?
Frequent urination?
Irregular periods (Women only)?
Severe cramps (Women only)?
Excessive flow (Women only)?
Any medicine for menstrual problems (Women only)?
Endocrine
YesYes, less than 1 year agoNo
An over-active thyroid?
An under-active thyroid?
Diabetes?
Neurology
YesYes, less than 1 year agoNo
A nervous breakdown?
Hospitalized for problems with your nerves?
Seizures in the past 5 years?
Recurring severe headaches?
Blackout spells (or episodes of confusion)?
Musculo-Skeletal
YesYes (>1yr ago)No
Back stiffness or pain which interferes with your normal activity for more than 7 days?
Troublesome joint stiffness, pain or swelling?
Rheumatoid arthritis?
An amputation of an arm or leg?
Skin
YesYes, less than 1 year agoNo
Troublesome acne?
Persistant or recurrent skin rash?
Mole(s) that change in size or color?
Hematology-Blood
YesYes, less than 1 year agoNo
Serious blood reaction to a drug treatment?
Anemia?
Emotional
YesYes, less than 1 year agoNo
Do you feel lonely or depressed most of the time?
Do you feel pressured most of the time?
Have you seriously contemplated or recently attempted suicide?
Have you obtained help from a mental professional?
Have you refused mental health help?
Do you feel you have serious nervous or emotional problems?
Would you find counseling useful for any of your problems?

When significant emotional problems are evident, the admissions committee will be informed. Records and advice may be needed from your previous health care providers. If adequate facilities (consistant with the principles of our religious denomination) do not exist at the college or in the community should continued care be needed, recommendation will be made for other schools where your needs may be more adequately met.

General Medical
For any prescription medicine (shots) which you wish the Health Service to administer to you, you must bring a written order signed by your physician. This order must name the medicine and must include the amount to be given, the frequency and method of administration, and how long this medication is to be continued.
YesNo
Has a physician told you that you should have an operation that you still need?
Are you sensitive to any drugs?
Other allergies?
Childhood diseases
YesNo
Chickenpox?
Measles (Red)?
Measles (German)?
Mumps?
Scarlet Fever?
General Profile

If you are under 19 years old, and therefore legally a child in the State of Nebraska, you will need to print the following form and have a parent or legal guardian sign and date it, and then mail it to us: Health Authorization

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