Updated 4/2016
MILLSAPS'COLLEGE'
WESSON HEALTH CENTER
Health History Form
Name _______________________________________________________________________________
(Last) (First) (Middle)
MILLSAPS STUDENT ID # ____________________________________________________________
Freshman year _______________________ Junior year ___________________
Sophomore year ______________________ senior year ___________________
Trad. __________ Grad. __________ Spec. __________
TO THE APPLICANT AND THE PHYSICIAN:
The Health History Form is required for all entering students to complete registration. Please fill out the Health
History Form. In order to render more efficient medical care to Millsaps students, the Wesson Health Center staff
must have an accurate and comprehensive record of each student’s present and past medical experience. Any
condition which might affect the student’s academic progress or require special attention should be reported.
Effort will be made to facilitate continuation of a plan of treatment for the welfare of the student if specific
instructions are furnished by the personal physician.
The Mississippi State Board of Health in conjunction with the Board of Trustees of the Institutions of Higher
Learning require that all new and transfer students must show proof of documented history of two doses of MMR
(measles, mumps, rubella) vaccine. It is VERY IMPORTANT that you complete your immunization information.
Please note that documentation must be from a healthcare provider (family physician, health department, etc.)
This form is used as a permanent record during the student’s entire time at Millsaps and is strictly confidential. If
you have any questions please call the Office of Student Life at 601-974-1206.
THIS FORM MUST BE COMPLETED BY AUGUST 1 : Forms may also be submitted to the following email
address: healt[email protected] or mailed to Millsaps College, Wesson Health Center, 1701 N. State St., Jackson, MS
39210, or faxed to 601-974-1768. Do not turn in or fax to any other office or department.
MEDICAL HISTORY
(To be completed by applicant)
Student’s Name ___________________________________________________Age______Sex______
(Last) (First) (Middle)
Date of Birth _______________________________________Marital Status ____________________
Parents’ or Spouse’s Name ____________________________________________________________
Home Address ______________________________________________Telephone________________
City ______________________________________________ State_________Zip_________________
Parents’ Business Address (Mother) ____________________________Telephone _______________
Parents’ Business Address (Father) _____________________________Telephone_______________
Updated 4/2016
PAST MEDICAL HISTORY (Circle those which you have had and note date)
Measles (Red) _________German Measles _________ Mumps __________ Chicken Pox __________________
Hay Fever ___________Asthma __________Rheumatic Fever__________Diabetes_______________________
Hepatitis (A, B, C or other) _________Epilepsy_______ Tuberculosis __________________
Recurrent Tonsillitis_________Blood Disorder/Anemia _________________________
Digestive Disorder_________Bone/joint Problems____________ Psychological Condition________________
Other (specify) ________________________________________________________________________________
REMARKS concerning the above _______________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
OPERATIONS/SERIOUS INJURIES – give dates__________________________________________________
_____________________________________________________________________________________________
Do you wear glasses or contact lenses? (check) ____ No ____ All the time ____ Reading only ____ Outside only
Do you take any medicine or drugs? _____________________________If so, what and why?_______________
Do you use tobacco products? (check) _____Yes _____No
Are you allergic to any medicine or drug? ________________________ If so, give details. _________________
_____________________________________________________________________________________________
Are you now covered by hospitalization insurance? __________ If so, what company? Give the subscribers name.
_______________________________________________________________Insurance Number ______________
Do you know of any reason why you will not be able to participate in all college activities, including athletics?
___________ If so, give reason. __________________________________________________________________
_____________________________________________________________________________________________
EMERGENCY CONSENT FOR MINORS – Signatures Required
Students under 18 years of age cannot give legal consent to be treated in case a medical or psychological emergency
arises. In such cases, are you willing to give permission for emergency treatment to be administered? ______ Yes
_____ No
Signature of parent or guardian ____________________________________________Date _________________
Signature of student ______________________________________________________Date _________________
Updated 4/2016
Certificate of Immunization Compliance
Tuberculosis Screening
Screening for Tuberculosis is required for all international students entering Millsaps College for the first time. A
blood test (interferon gamma release assay, i.e. IGRA) is required during the week of orientation and must be done
in the Mississippi State Department of Health Clinic at the Jackson Medical Mall. Directions will be given and
transportation arranged once you have arrived on campus. Cost of the test is $50.00 and will be charged to your
student account. Chest x-rays and/or reports from outside the USA will be not accepted. International students
entering Millsaps College for the first time are also required to meet the same immunization requirements as
domestic students. See Certificate of Compliance below.
2 MMR (Measles, Mumps, and Rubella) vaccines – 1
st
after 12 months of age, 2
nd
at 5 years old or later are
required for admission to Millsaps College. A Meningitis vaccine and a Tetanus booster are strongly
recommended. The Wesson Health Center staff will follow up on this to ensure documentation is provided.
Name of Student ___________________________________________________ Birthdate __________
Millsaps College Student ID #________________
Address ____________________________________________________________________________
Street City State Zip
Date Each Dose Was Given
Vaccine 1
st
2
nd
3
rd
4
th
5
th
DTP/DTaP/DT/Td
Polio (OPV or IPV)
Hep B
MMR
Varicella
Other
Other
Health Dept. or Clinic Signature _______________________________________________________
Date Form Completed ______________________________________________________________________
