Health Record & Consent Form 2025-2026

Health Record & Consent Form

This health record is a requirement for admission to Hiram College and must be on file in the Health Center. Please complete this form and click the "submit" button at the bottom. You will be redirected to a confirmation message upon successful submission.
Please read through the form in it's entirety and ensure that you have all the information necessary to complete it. You will not be able to click submit until you have completed all the required fields.
Full Name*

First NameMiddle NameLast Name
Preferred First Name
Date of Birth*

MonthDayYear
Are you age 18 or over?*

YesNo
Gender*
Preferred Pronouns
Cell Phone*
\
Is it ok to leave messages regarding your health center visits at this number?
Email*
Student ID Number*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent Name*

First NameLast Name
Business or Cell Phone*
Emergency Contact*

First NameLast Name
Relationship*

Personal History-Have you had any of the following: *

	YES	NO	N/A
ADD/ADHD
Alcohol or Drug Dependency
Anemia
Anxiety
Any Chronic Disease
Appendicitis
Arthritis
Asthma
Bipolar Disorder
Blood Diseases
Broken Bones
Bronchitis
Cancer
Chicken Pox
Concussion
Depression
Diabetes
Ear Infections
Eating Disorders
Headaches (severe)
Hepatitis
Hernia
Heart Disease
Heart Murmur
High Blood Pressure
Kidney Disease
Mononucleosis
Other Serious Illness or Injuries
Pneumonia
Psychological Counseling
Rheumatic Fever
Seizures
Skin Disease
Stomach or Intestinal Problems
Suicide Attempt
Thyroid Disease

Explanations of any "yes" answers from above
List any other surgeries or hospitalizations
Please list all medications/birth control/supplements that you are currently taking
Make sure you press the "SAVE" button after each entry to add it to the form. You may make multiple entries.
Allergies: (if none, please type n/a in each box) *
Do you currently have or have you ever had an Epi-Pen for an allergy?*
Required Immunization Records
A) M.M.R. (MEASLES, MUMPS, RUBELLA) (Two doses required)

1. Dose 1 given at age 12-15 months or later

2. Dose 2 given at 4-6 yrs. or at least 28 days after first dose
Dose #1*

MonthDayYear
Dose #2*

MonthDayYear
B) TETANUS-DIPHTHERIA-PERTUSSIS
Primary series with DTaP, DTP, DT, or Td, and booster with TD or Tdap in the last ten years. Many children recieve 5 doses of primary vaccination. We only require 4 dates of this childhood series.

1. Primary series of four doses with DTaP, DTP, DT, or Td:
Dose #1*

MonthDayYear
Dose #2*

MonthDayYear
Dose #3*

MonthDayYear
Dose #4*

MonthDayYear
Date of Booster Shot: Tdap (preferred) or TD within the last 10 years: *

MonthDayYear
Type of Booster Shot*
C) Meningococcal and Hepatitis B Vaccine Status

(as required by Ohio Revised code, 3701.133,13)
Ohio law requires all students to be made aware of the risks of Meningococcal and Hepatitis B infections in the college setting.

Meningococcal Disease and College Students

Hepatitis B and College Students
Have you received a Meningococcal ACWY vaccine?*

YesNo
If yes, please enter date.*

MonthDayYear
Have you received a Meningococcal B vaccine?*

YesNo
If yes, please enter date*

MonthDayYear
Have you received a Hepatitis B vaccine series?*

YesNo
Dose #1*

MonthDayYear
Dose #2*

MonthDayYear
Dose #3*

MonthDayYear
Required Immunization Exemption Form

If you are applying for an exemption from any required immunizations please enter 01-01-1111 for the dates.
Recommended but not required.

Please use 01-01-1111 in the date boxes if you have not been received these immunizations.
COVID-19 Vaccine
Name of vaccine administered
Dose #1

MonthDayYear
Dose #2 (if you received J&J, enter all ones)

MonthDayYear
Proof of Vaccination

Insert image of vaccine card
Cancelof
VARICELLA (Chicken Pox)
History of Disease

YesNo
Vaccinated #1

MonthDayYear
Vaccinated #2

MonthDayYear
HEPATITIS A

1. Immunization (Hepatitis A)
Dose #1

MonthDayYear
Dose #2

MonthDayYear
2. Immunization (Combined Hepatitis A and B vaccine)
Dose #1

MonthDayYear
Dose #2

MonthDayYear
Dose #3

MonthDayYear
GARDASIL
Dose #1

MonthDayYear
Dose #2

MonthDayYear
Dose #3

MonthDayYear
TUBERCULOSIS SCREENING

The American College Health Association has published guidelines on tuberculosis screening of college and university students. These guidelines are based on recommendations from the Centers for Disease Control and the American Thoracic Society. For more information visit ACHA.

Categories of high risk students include those students who have arrived within the past 5 years from countries where TB is endemic. Click here to determine if your country is high risk.

Other categories of high-risk students who should receive a TB test include those with HIV infection, who inject drugs, who have resided in, volunteered in, or worked in high-risk congregate settings such as prisons, nursing homes, hospitals, residential facilities for patients with AIDS, or homeless shelters; and those who have clinical conditions such as diabetes, chronic renal failure, leukemias or lymphomas, low body weight, gastrectomy and jejunoileal by-pass, chronic malabsorption syndomes, prolonged corticosteroid therapy (e.g., prednisone 15 mg/d for 1 month) or other immunosuppressive disorders.
1. History of BCG?*

YesNo
2. Is the student a member of a high-risk group?*

YesNo
3a. Tuberculin Skin Test: Date Given

MonthDayYear
3b. Tuberculin Skin Test: Date Read

MonthDayYear
Result: (record actual mm of induration, transverse diameter, if no induration, write "0")
Interpretation (based on mm of induration as well as risk factors:
5. Date of chest x-ray (required if tuberculin skin test is positive):

MonthDayYear
Do you have health insurance?*

YesNo
If yes, upload front & back copy of insurance card or input insurance card information below.

Cancelof
If no, click here for more information about coverage.
Insurance Name
ID Number
Group Number
Claims Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Claims Office Phone
(on card)
Claims Office Fax
(on card)
Policy Holder Name

First NameLast Name
Policy Holder Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Policy Deductible
Policy Co-pay
Prescription Insurance Carrier (on insurance card)
Prescription ID #
Bin #
RX Group #
Insurance Pharmacy Provider Phone Number
(on card)
Please upload any additional information using the button below. (i.e. prescription card)

Cancelof
Consent and Release

Permission is hereby voluntarily granted to the Director of Student Health Services, the College Physician(s), nurses, counselors and employees of the Julia Church Health Center to do all such things as may be necessary to diagnose, treat and care for the needs of the named student. I am aware that the practice of medicine and surgery is not an exact science, and I acknowledge that no guarantees have been made to me as the result of the treatment or examination in the Julia Church Health Center.

I certify that I understand the contents of this consent form, and that my signature represents a free voluntary act of consent there to on behalf of the student. I further certify that I expect any specific information regarding any service from the Julia Church Health Center will not be released without the express written consent of the student unless disclosure is mandated by law or in the professional judgment of the Director of Health Services or the College Physician(s) is necessary to protect the physical safety of the student or the community at large.

I hereby authorize any health care facility or health care provider to furnish to the Director of Student Health Services or the College Physician(s) medical records and information pertaining to the medical history, mental or physical condition, services rendered, or treatment of the patient named below. This authorization shall remain in effect until revoked in writing. A photocopy of this authorization shall be deemed as valid as the original.

In case of illness or accident deemed serious by the Director of Student Health Services or the College Physician(s), I authorize said persons to notify the parent or guardian named on my medical history form, and the Dean of Students Office if I am unable to do so. I hereby authorize the College Physician(s), College Counselor or Director of Student Health Services to refer me to the appropriate facility for evaluation in case of medical or mental health emergency.

Student athletes: The Julia Church Health Center and the Hiram College Athletics work in conjunction to achieve the best patient outcomes for our student athletes. I hereby authorize release of medical information that is relevant to my participation in athletics to the Hiram College athletic trainers, coaching and/or administrative staff, Hiram College team physician and/or associates.

The Privacy Act Practices Document has been provided for me, I am aware it can be found at http://www.hiram.edu/images/pdfs/health-services/privacy-act-practices.pdf . I have read the document and understand my privacy rights as a patient in the Hiram College Julia Church Health Center.
Signature of Student*
Signature of Parent/Guardian (if student is less than 18 years of age)
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Health Record & Consent Form

Required Immunization Records

Recommended but not required.

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