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The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

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This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

QyeCzxSHCZmwAdVood2tavYgvVH3zGUjaoSiD9IWxyLPLwMFAujerQn737XBSbCx8KDsS74zAjKHxngqpIviqbR

Student Health and Wellness Client Information Sheet

Our office hours are 8am-5pm Monday-Friday.

If you are submitting Health Forms outside of these office hours, our staff will be unable to respond until our regular business hours. If this is an emergency, please call 911.

Date Submitted

Full Name (as found on your permanent file)

* must provide value

Date of Birth

* must provide value

M-D-Y

Phone number, where we can reach you at any time

* must provide value

HSU ID# (above bar code on ID)

* must provide value

Email address, that you check, where we can get in contact with you

* must provide value

Race / Ethnic Background

* must provide value

Black / African American

Native American or Alaskan Native

Asian American

Asian

Caucasian / White

Hispanic / Latino

Native Hawaiian or Pacific Islander

Multi-racial

Prefer not to disclose

Biological Gender

* must provide value

Male

Female

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Gender you most identify with

* must provide value

Male

Female

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Sexual Preference

* must provide value

Heterosexual/Straight

Homosexual

Bisexual

Other

Are you currently enrolled in classes this semester?

* must provide value

Yes

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Is this visit your fist time seeing any of our nursing staff as a patient?

* must provide value

Yes

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Reason for seeing our nursing staff/Current symptoms

* must provide value

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Student Classification

* must provide value

Do you live

* must provide value

On campus

Off Campus

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List on campus dorm/apartment or off campus address

* must provide value

Do you have Health Insurance?

* must provide value

Yes

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Emergency Contact Name/relationship

* must provide value

Emergency Contact phone number

* must provide value

List any medical diagnosis/medical conditions

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List past surgeries

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List current medications you are taking (prescription or over the counter)

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List any drug allergies

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Are you an AVIATION student? (question asked due to contraindications of some medications that we may prescribe)

Yes

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Little interest or pleasure in doing things:

Not at all

Several days

More than half of the days

Nearly every day

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Feeling down, depressed, or hopeless

Not at all

Several days

More than half of the days

Nearly every day

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Number of Covid-19 Vaccine Doses you have received

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Have you received the seasonal flu vaccine in the last 6-8 months?

Yes

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Do you have any of the following symptoms?

Fever greater than 100.4 or chills

Cough

Shortness of breath

Sore throat

Fatigue

Unexplained muscle or body aches

Headache

New loss of taste or smell

Congestion or runny nose

Nausea or vomiting

Diarrhea

If you have any of the above symptoms, when did they start?

Please list any questions or concerns you would like to discuss during your visit.

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Henderson Student Health and Wellness is required by law to maintain the privacy of protected health information and to provide you with this notice of our duties and privacy practices with respect to protected health information. This notice describes how medical information about you may be used and disclosed and how you can access this information. Please review this document. You may request a copy of this notice. Other uses and disclosures will be made only with your written authorization.

We will use your health information for treatment. Information obtained by your healthcare provider is recorded in your chart to determine the course of treatment that will work best for you. Your healthcare team members record the actions they took and their observations.
We will use your health information for regular operations. We may use information from your health record to assess the care and outcomes in your case and others like it. This information is used in an effort to continually improve the effectiveness of the healthcare and the service that we provide.
We may contact you to provide appointment reminders, reminders of needed follow-up care, or missed appointments.
We may disclose to the FDA health information relative to adverse effects of food, medications, supplements, products, or product defects.
We may disclose health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability, as required by law.
We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.
We may disclose health information to the Vice Chancellor of Student Affairs, or the Director of Judicial Affairs in the Vice Chancellor's absence, if we feel that you pose a significant threat of danger or physical harm to yourself or to other members of the Henderson community.

You have the right to review the notice prior to signing the consent. Student Health and Wellness has the right to change their notices and practices. You may print a copy for your records.

You have the right to request restrictions as to how your health information may be used to carry out treatment or healthcare operations. Student Health and Wellness does not have to agree to the restrictions requested. The consent may be revoked in writing, except to the extent that Student Health and Wellness has already taken action in reliance thereon.

If you believe your privacy rights have been violated, you can file a complaint with the Director of Student Health and Wellness, the Vice Chancellor of Student Affairs, or with the Secretary of Health and Human Services.

EFFECTIVE: 8/21

Patient/Student Signature

Add signature

Name of Health Insurance Company

Insurance Card Photo

Upload file

Photo ID

Upload file

Do you consume alcohol?

Yes

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Are you an AVIATION student at HSU?

Yes

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Little interest or pleasure in doing things

Feeling down, depressed, or hopeless

Have you traveled outside of the United States in the last 14 days?

Yes

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Where did you travel?

In the last 14 days have you been in direct contact with someone confirmed to have COVID-19?

Yes

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When were you in direct contact with this person?

M-D-Y

Have you been diagnosed with COVID-19 in the last 90 days?

Yes

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When were you diagnosed?

M-D-Y

Have you been vaccinated for COVID-19?

Yes

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Vaccination Type

First Vaccination Date

M-D-Y

Second Vaccination Date

M-D-Y

Do you have any of the following symptoms?

Fever greater than 100.4 F or chills

Cough

Shortness of breath

Sore throat

Fatigue

Unexplained muscle or body aches

Headache

New loss of taste or smell

Congestion or runny nose

Nausea or vomiting

Diarrhea

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