Health History & Physical Examination Form

DUE DATE: AUGUST 1

(FALL SEMESTER)

JANUARY 1

(SPRING SEMESTER)

. According to NYS Health Law, all students registered for 6 or more credits must provide

proof of immunity to measles, mumps & rubella and either receive or decline the meningitis

vaccine. Failure to do so will result in withdrawal from class.

2. All incoming full time students must provide the Health & Wellness Center a health history

SUNY Poly

and physical exam completed by a healthcare provider within the last 2 years. Failure to provide a

Health & Wellness Center

physical exam will result in an academic hold, prohibiting your ability to access your student

100 Seymour Road

account, obtain grades or register for additional courses. ALL Department of Nursing students are

Utica, NY 13502

required to use this form for medical documentation submission. ALL Intercollegiate athletes must

Phone: 315.792.7172

have a physical exam within 6 months of their sport start date; including non-traditional season.

Fax:

315.792.7371

Contact the respective departments with questions.

3. Confidential Form. Information is for use at the SUNY Poly Health & Wellness Center only and will not

be released without the student’s written consent, or a court order.

Please Print

Student Identification

College Related Information

Name

Entering term:  Fall  Spring Year ________

________________________________________________________________

Year expected to graduate: _____________

Last

First

Middle

Home address ____________________________________________________

 Freshman  Sophomore

________________________________________________________________

 Junior

 Senior

 Graduate

Local address (if known) ____________________________________________

Current Health Care Provider (Physician)

Home phone (

)

Cell phone (_____)_______________

Name ___________________________________________

Birth date: ____ ____ - ____ ____ - ____ ____ ____ ____ Age: ____________

Address _________________________________________

Gender:

 Female

 Male

 Other ___________

__________________________________________

Race:

 White/Non Hispanic

 African American  Native American

Phone (_____)_________________________

Medical Insurance

 Asian

 Hispanic

 Other ___________

SUNY Poly requires all domestic students taking 12 or

more credits & ALL nursing students regardless of credit hours to

Emergency Contact Information

have medical insurance coverage. Enrollment and billing is

Name ___________________________________ _______________________

automatic unless you waive the designated SUNY Poly

medical insurance your first semester, then each fall semes-

Address _________________________________________________________

ter thereafter. Once you receive your PIN number you MUST

________________________________________________________________

waive the medical insurance electronically.

SUNY requires all international students entering the

Home phone (

)

Cell phone (_____)____

______

country for study or research to purchase a SUNY medical

Business phone (_____)______________ Relationship ____________________

insurance policy

tudents are enrolled and billed automatically.

ALL MEDICAL INFORMATION IS CONFIDENTIAL

Consent for Medical Care: All registered students AND parent/guardian of students under 18 years of age MUST sign.

I hereby give permission to the SUNY Poly medical/nursing staff to examine and treat (Student’s name)______________________________

for all medical problems/injuries while he/she is at SUNY Poly. In the event of time restraints, or that I cannot be reached, I hereby give permis-

sion for the Health & Wellness Center staff to secure consultative care that may include hospitalization, anesthesia, surgery and/ or other

medical treatment. I also give permission for the SUNY Poly medical/nursing staff to share pertinent health information with the SUNY Poly

Counseling and Disability Services staff as deemed necessary. I understand that I have the right to revoke this consent at any time.

__________________________________________________ AND _________________________________________________

Student signature

Date

Parent/guardian signature IF student is under 18 years old

Date

Intercollegiate Athletes:

I hereby give permission to both the SUNY Poly Health & Wellness Center and Athletics to share pertinent health information

Student signature ________________________________ Date ____________

between each other for participation in intercollegiate sports.

Nursing Students

: I hereby give permission to both the SUNY Poly Health & Wellness Center and the Department of Nursing to share pertinent health

Student signature ________________________________ Date ____________

information between each other for clinical activity.

Health History & Physical Examination Form - Suny Poly

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