International Student Health Report

CENTER FOR STUDENT HEALTH AND PSYCHOLOGICAL SERVICES

Immunization Record and Physical Examination Forms

Step One: Download the Immunization Record and the Physical Examinations Forms to be completed by your healthcare provider.

Immunization Record

Physical Examination Form

Step Two: Give the forms to your provider to complete.

Step Three: Scan the completed forms and upload them to this report.
Upload Immunization Record (PDF)

Attach Files
Upload Physical Examination Form (PDF)

Attach Files
Parental Consent for Students Under 18 Years of Age

If you are under 18 years of age you must have your parent or guardian complete the Emergency Conset Form and upload it here.

Emergency Consent Form
Upload Emergency Consent Form (PDF)

Attach Files
Meningococcal Vaccination Response Form

New York State public health law requires all students to complete and return this page before attending classes.

Meningococcal Vaccination Response Form
Upload Meningococcal Vaccination Response Form

Attach Files
Family Name
Given Name
ID Number (i.e. your 700 number)
Gender
Date of Birth Date of Birth / MM / DD YYYY
Semester of Enrollment
Permanent Address

Type exactly as it should appear in English on an envelope.
Email
EMERGENCY PERSON CONTACT INFORMATION

To Be Completed By Student
Family Name
Given Name
Home Phone Number of Emergency Contact

Country code, City code, Number
Other Phone Number of Emergency Contact

Country Code, City Code, Number
Home Address of Emergency Contact
Email
Relationship to you (e.g. father, mother)
MEDICAL HISTORY

To Be Completed By Student
Family Name
Date of Birth Date of Birth / MM / DD YYYY
Have you ever been or are currently treated for any of the following (check appropriate boxes)?

Have you ever been or are currently treated for any of the following (check appropriate boxes)? Abnormal PAP smear Alcohol/substance abuse Allergies/hay fever Anorexia Back problems Blood disorders Bulimia Cancer Chicken pox Convulsions/seizures Cystitis or urinary infections Diabetes Disorders of eye, ear, nose or throat Depression/anxiety Gynecological disorders Head injury/concussion Heart disease/murmur Hepatitis Hypoglycemia Hernia High blood pressure Infectious mononucleosis Inflammatory bowel syndrome Injure to legs, feet, arms, or hands Kidney disease Loss of consciousness Migraine headaches Rheumatic fever Sexually transmitted infections Thyroid disease
Please explain everything you checked above
Have you ever been hospitalized or had any surgery? If yes, please describe the problem, when it occurred, and where.
Have you ever had any sports-related injuries? If yes, please describe.
Do you have any restrictions on your physical or learning activity? If yes, please describe.
Do you have allergies to food, medications, or latex? If yes, please describe.
Please list any medications, vitamins, supplements, or birth control that you take on a regular basis (include the name, dose, and frequency of the item).
Does your family have a history of any of the following (check appropriate box)?

Does your family have a history of any of the following (check appropriate box)? Alcoholism Cancer Chronic lung disease Depression Intestinal disorders Heart disease High blood pressure Diabetes Kidney disease
Please explain everything you checked above
Voluntary Self-Identification: Please complete this question if you have a physical or learning disability and would like to receive information about specific services that may be available to support your success in college. This questions is optional , wil remain confidential, and will not in any way affect your academic of personal status at this college. Describe the nature of your disability.

International Student Health Report

International Student Health Report

Immunization Record and Physical Examination Forms

Parental Consent for Students Under 18 Years of Age

Meningococcal Vaccination Response Form

EMERGENCY PERSON CONTACT INFORMATION

MEDICAL HISTORY