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    Health Form - 2025

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    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
    Mailing Address
    Mailing Address
    Birthdate
    Birthdate
    Sex
    Sex
    Emergency Contact
    Health Insurance
    Do you have health insurance?
    Do you have health insurance?

    Part II: Personal Medical History
    Have you had any serious injury, operation, illness, or disease?
    Have you had any serious injury, operation, illness, or disease?
    Have you received out-patient treatment or been hospitalized for an emotional health issue?
    Have you received out-patient treatment or been hospitalized for an emotional health issue?
    Are you currently taking any prescribed or over-the-counter medications or treatments?
    Are you currently taking any prescribed or over-the-counter medications or treatments?
    Do you have reactions to any medicine or antibiotics?
    Do you have reactions to any medicine or antibiotics?
    Do you have any allergies? Check all which apply and specify:
    Do you have any allergies? Check all which apply and specify:
    Part III: Immunization Record
    Indicate your immunity by checking the appropriate boxes and then specifying relevant dates below:
    1. Tetanus/Diphtheria
    1. Tetanus/Diphtheria
    DPT Date:
    DPT Date:
    Tetanus Date:
    Tetanus Date:
    2. M.M.R. (Measles, Mumps, Rubella) If you have had MMR vaccine
    2. M.M.R. (Measles, Mumps, Rubella) If you have had MMR vaccine
    DOSE 1 Date:
    DOSE 1 Date:
    DOSE 2 Date:
    DOSE 2 Date:
    3. Varicella (Chicken Pox)
    3. Varicella (Chicken Pox)
    Disease Date:
    Disease Date:
    Vaccine Series Date:
    Vaccine Series Date:
    4. Polio
    4. Polio
    Vaccination Date
    Vaccination Date
    5. Hepatitis B
    5. Hepatitis B
    Disease Date:
    Disease Date:
    Vaccine Series Dates:
    Vaccine Series Dates:
    6. Meningitis
    6. Meningitis
    Vaccine Date:
    Vaccine Date:
    Men ACYW (Menactra or Menveo)
    Dose 1 Date:
    Dose 1 Date:
    Dose 2 Date:
    Dose 2 Date:
    Men B (Bexsero)
    Dose 1 Date:
    Dose 1 Date:
    Dose 2 Date:
    Dose 2 Date:
    7. COVID-19 Vaccine
    7. COVID-19 Vaccine
    Dose 1 Date:
    Dose 1 Date:
    Dose 2 Date:
    Dose 2 Date:
    Booster Date:
    Booster Date:
    Part IV: Tuberculosis (TB) Screening Questionnaire
    Show list of high incidence countries:
    Show list of high incidence countries:
    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
    Have you ever had close contact with persons known to suspected to have active TB disease?
    Have you ever had close contact with persons known to suspected to have active TB disease?
    Have you had frequent or prolonged visits to one or more of the countries listed with a high prevalence of TB disease?
    Have you had frequent or prolonged visits to one or more of the countries listed with a high prevalence of TB disease?
    Have you been a resident and/or employee of high-risk congregate settings? (e.g., correctional facilities, long-term care facilities, and homeless shelters)?
    Have you been a resident and/or employee of high-risk congregate settings? (e.g., correctional facilities, long-term care facilities, and homeless shelters)?
    Have you been a volunteer or health-care worker who served clients who are at increased risk for active TB disease?
    Have you been a volunteer or health-care worker who served clients who are at increased risk for active TB disease?
    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?
    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?
    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:
    Date:
    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.
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    Ripon College
    Office of Admission
    300 W. Seward St.
    Ripon, WI 54971
    Phone: 920-748-8709
    Email: adminfo@ripon.edu
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