Point Park University Student Medical Report Form

Point Park University Student Medical Report Form

This document is MANDATORY for all incoming students. Please send all forms to the health office prior to the deadline date. A failure todo so will result in an academic hold and the inability to register for classes. All information attained from the Student Medical Report Form is confidential and only viewed by the medical staff in the Student Health Center. The information in this document will not be released to anyone without consent. A consent to release medical information form must be signed by the student for the medical staff to speak with any other party about any medical care provided or any health history. FALL DEADLINE AUGUST 1ST, SPRING DEADLINE JANUARY 1ST
Admission Status*

New Undergraduate AdmissionTransfer StudentReadmissionGraduate Student
Term of Entry*

FallSpring
Housing Plans*

On campusOff campus
International Student?*

YesNo
Full Name*

First NameMiddle NameLast Name
Preferred Name
Preferred Name
Student ID Number*
What is your date of birth?*
ex: MM/DD/YYYY
What is your gender?*
Legal Sex*
Student Personal Number*
Student Email Address
example@example.com
Student Athlete?*

YesNo
Student Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Care Physician
Primary Care Physician Phone Number
Emergency Contacts*
Name and Relationship
Emergency Contact Phone Number*
Emergency Contacts*
Name and Relationship
Emergency Contact Phone Number*
Health History: Please select any that apply*

Eye TroubleEar TroubleThroat ProblemsDiabetesSkin TroubleHeart ProblemsDisease/injury of the JointsSeizuresDizziness/FaintingTumors/Cancer/CyestsBreathing Problems/ AsthmaStomach ProblemsEating disorders or weight problemsChronic Migraines or HeadachesInsomniaHearing DifficultiesSeasonal AllergiesBack/Spinal Cord ProblemsAnxietyDepressionHead InjuryOther Mental Health DiagnosesConcussionOther
Do you have a history of any major illness or hospitalization?*

YesNo
Please list them.
Are you currently taking any medication?*

YesNo
Please list them.
Do you have any medication allergies?*

YesNoNot Sure
Please list them.
Do you have any food allergies?*

YesNoNot Sure
Please list them.
Do you use any kind of tobacco or have you ever used them?
What kind of tobacco products? How long have you used/been using them?
Do you use any kind of illegal drugs or have you ever used them?
What kind of drugs? How long have you used/been using them?
How often do you consume alcohol?

DailyWeeklyMonthlyOccasionallyNever
Health Insurance*
Insurance Company Name
Name of Primary Person Insured
Group Number
Address of Primary Person
Member ID Number
Phone Number of Primary Person
Needs Assessment

The success of our students depends on many factors. Part of our commitment to wellness at Point Park University is to ensure students have access to the correct resources. Use the form below to help us meet the needs of our students. If you designate a need, we will provide the corresponding office’s information on its services and how to access them. This information is kept confidential.
Do you need assistance transferring prescription medications to Pittsburgh for refills?*

YesNo
Have you struggled with or do you currently struggle with any mental health challenges?*

YesNo
Would you be interested in connecting with the University Counseling Center?*

YesNo
In the past, have you had any accommodations for any disability in school?*

YesNo
Do you plan to request accommodation at PPU?*

YesNo
Please be advised that to request medical or other reasonable accommodations, individuals must register with Accessibility Services and provide all necessary documentation to Accessibility Services by July 1, 2024.
Do you have difficulty affording food?*

YesNo
Do you have difficulty affording hygiene items like soap, laundry detergent, or menstrual care products?*

YesNo
Do you have difficulty affording any technology items that could impact your learning such as Wi-Fi, a computer, etc.?*

YesNo
Are you a veteran?*

YesNo
Are you a parenting student that needs assistance/support with parenting needs(cohort support, childcare resources, etc.)*

YesNo
Consent and Authorization

By submitting this form, I confirm that the information provided is accurate to the best of my knowledge. I give my consent to receive medical care and treatment from Point Park University Student Health Services. I also authorize the use of electronic communication through Practice Fusion, including appointment reminders, secure messages, and notifications related to my care. I understand that my health information will be managed in accordance with HIPAA regulations and the university’s privacy policies.
Should be Empty:

Point Park University Student Medical Report Form

Needs Assessment

Consent and Authorization