Health Form

Please read before beginning the health form:

During your attendance at Ripon College you will have available to you facilities and services outlined in the Ripon College Catalog and Handbook, in the section entitled "Health Services." In order to provide properly for your health needs, Health Services must have the information requested on this form as the basis for the health record which will be maintained for you as a Ripon student. You will be eligible for routine care at Ripon College Health Services when this information is on file and registration has been completed.

Because you have already been accepted for admission, the information you supply will not affect your status at Ripon and will not be released to anyone except by your written authorization.

Student-athletes who plan to participate in DIII Athletics at Ripon College will be required to complete a physical in addition to this health form per NCAA regulations. More information will be sent from your respective coach.

This form is confidential. Please answer all questions.

Part I: Health History

First Name

Middle Name

Last Name

Mailing Address

Country

Street

City

Region

Postal Code

Mobile Phone

Home Phone

Email Address

Birthdate

Age

Sex

Female

Male

X or another legal sex

Emergency Contact

Emergency Contact Full Name

Emergency Contact Relationship
Ex: Mom, Dad, Step-parent, Grandparent, etc.

Emergency Contact Phone

Emergency Contact Email

Health Insurance

Do you have health insurance?

Yes

Insurance Company

Policy Owner

ID Number

Group Number

Please upload a copy of the front and back of the policy owner's health insurance card:

Part II: Personal Medical History

Have you had any serious injury, operation, illness, or disease?

Yes

If yes, explain and include dates:

Have you received out-patient treatment or been hospitalized for an emotional health issue?

Yes

If yes, explain and include dates:

Are you currently taking any prescribed or over-the-counter medications or treatments?

Yes

If yes, please note medications and dosages:

Do you have reactions to any medicine or antibiotics?

Yes

List type of reaction and what causes it:

Specify:

Do you have any significant problems which have not been listed in the section above? Please go into detail:

Part III: Immunization Record

Indicate your immunity by checking the appropriate boxes and then specifying relevant dates below:

1. Tetanus/Diphtheria

Primary series of DPT completed

Tetanus Booster (within the last 10 years)

DPT Date:

Tetanus Date:

2. M.M.R. (Measles, Mumps, Rubella) If you have had MMR vaccine

DOSE 1 (After 12 mos. and before 5 years old)

DOSE 2 (5 years old or after)

DOSE 1 Date:

DOSE 2 Date:

3. Varicella (Chicken Pox)

Had disease

Vaccine Series

Disease Date:

Vaccine Series Date:

4. Polio

Completed Primary Vaccination Series

Vaccination Date

5. Hepatitis B

Had disease, confirmed by office record

Disease Date:

Vaccine Series Dates:

6. Meningitis

Vaccine

Vaccine Date:

Men ACYW (Menactra or Menveo)

Dose 1 Date:

Dose 2 Date:

Men B (Bexsero)

Dose 1 Date:

Dose 2 Date:

7. COVID-19 Vaccine

Vaccine

Dose 1 Date:

Dose 2 Date:

Booster Date:

Part IV: Tuberculosis (TB) Screening Questionnaire

Show list of high incidence countries:

Click to show or hide list

Afghanistan
Algeria
Angola
Argentina
Armenia
Azeribaijan
Bahrain
Bangladesh
Belarus
Belize
Benin
Bhutan
Bolivia (Plurinational State of)
Bosnia and Herzegovina
Botswana
Brazil
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Central African Republic
Chad
China
Colombia
Comoros
Congo
Cote d'Ivoire
Democratic People's Republic of Korea
Democratic Republic of the Congo
Dominican Republic
Ecuador
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Gabon
Gambia
Georgia
Ghana
Guatemala
Guinea
Guinea-Bíssau
Guyana
Haiti
Honduras
India
Indonesia
Iran (Islamic Republic of)
Iraq
Kazakhstan
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lesotho
Liberia
Libya
Lithuania
Madagascar
Malawi
Malaysia
Maldives
Mali
Marshall Islands
Mauritania
Mauritius
Micronesia (Federated States of)
Mongolia
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Nicaragua
Niger
Nigeria
Niue
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Republic of Korea
Republic of Moldova
Romania
Russian Federation
Rwanda
Saint Vincent and the Grenadines
Sao Tome and Principe
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Solomon Islands
Somalia
South Africa
South Sudan
Sri Lanka
Sudan
Suriname
Swaziland
Tajikistan
Thailand
Tímor-Leste
Togo
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Republic of Tanzania
Uruguay
Uzbekistan
Vanuatu
Venezuela (Bolivarian Republic of)
Viet Nam
Yemen
Zambia
Zimbabwe

Were you born in one of the countries listed below that have a high incidence of active TB disease?

Have you ever had close contact with persons known to suspected to have active TB disease?

Yes

Have you had frequent or prolonged visits to one or more of the countries listed with a high prevalence of TB disease?

Yes

Have you been a resident and/or employee of high-risk congregate settings? (e.g., correctional facilities, long-term care facilities, and homeless shelters)?

Yes

Have you been a volunteer or health-care worker who served clients who are at increased risk for active TB disease?

Yes

Have you ever been a member of any of the following groups that may have an increased incidence of latent M. tuberculosis infection or active TB disease: medically underserved, low-income, or abusing drugs or alcohol?

Yes

You've answered YES to one of the questions above. Ripon College requires that you receive TB testing as soon as possible, but at least prior to the start of the subsequent semester.

You've answered NO to all of the above questions. No further testing or further action is required.

Part V: Medical Treatment/Medical Permission

Information provided on this health form may be released to Ripon College athletic department if requested. Student health files will be maintained at Health Services for a period of seven years after date of last visit. Medical care provided at Health Services is without charge and includes nursing evaluation, available medications, available laboratory tests, health education materials and information. Permission is hereby granted to attending medical personnel to provide needed medical treatment, medication and immunizations for:

Student's Signature:

Parent/Guardian Signature if student is a minor:

Date:

Once you're ready to complete your Health Form, please click "Submit". This form can take 10-20 seconds to submit due to the amount of information being collected. Please do not click off of this page until you land on the confirmation page. If you encounter issues, contact us at 920-748-8709 or adminfo@ripon.edu.

Also, if you notice your health form is still marked as "Incomplete" on your checklist, please ignore this for now. We're doing some behind the scenes work and this is causing a temporary visual error. Please submit when you're ready.

Health Form - 2024