Fillable Printable Health History Form - Cornell University
Fillable Printable Health History Form - Cornell University
Health History Form - Cornell University
Please return this form to:
Gannett Health Services
110 Ho Plaza
Ithaca, NY 14853-3101
For information or assistance:
607.255.5155
Faculty, Staff, Dependent of Enrolled Student
Health History Form
Welcome to Gannett Health Services. Known as a primary care facility for the health needs of students, Gannett offers a range of services to Cornell employees
and eligible dependents of enrolled students. Gannett is accredited by the Accreditation Association for Ambulatory Health Care.
All medical care and counseling at Gannett is confidential. Health care records are completely separate from all other university records. Gannett Health Services
staff confer with one another as needed to provide integrated care for you; in the event of your treatment at Cayuga Medical Center or another hospital, the
hospital and Gannett will share relevant health information for continuity of care. Otherwise, Gannett will not release any information about you without your written
permission, except as authorized or required by law, or in our judgment as necessary to protect you or others from a serious threat to health or safety.
Gannett uses an electronic health records system, which provides a web portal (myGannett) to facilitate secure communication with our established patients.
Part ONe: IdeNtIFIcatION aNd PrIvacY
IdeNtIFIcatION
Status ⃞ Faculty member ⃞ Staff member ⃞ Dependent of enrolled student (specify) ________________________________________________________________________
Name _________________________________________________________________________Date of Birth
(mm-dd-yyyy) __________________________ Gender________________________
(last, first, middle)
Cornell ID# _________________________________________________________________________________Cornell Net ID _______________________________________________________
Address ____________________________________________________________________________________
Street or P.O. Box
_________________________________________________________________________________________________________________________________________________________________
City State/Province Zip or Postal Code
Phone NumbersHome _______________________________________Cell _______________________________________ Work _______________________________________
HealtH INSuraNce INFOrmatION
Subscriber Name ____________________________________________________________________________Relationship _________________________________________________________
Name of Insurance Company ___________________________________________________________________Policy # _____________________________________________________________
Address of Insurance Company _____________________________________________________________________________________________________________________________________
Gannett participates with a limited number of insurance plans. Learn more about paying for health care at Gannett: www.gannett.cornell.edu/access/fees
PerSON tO NOtIFY IN caSe OF emerGeNcY
Name ______________________________________________________________________________________Home phone ________________________________________________________
Relationship ________________________________________________________________________________Work or cell phone __________________________________________________
PrIvacY INFOrmatION
Gannett has a long-standing commitment to the rights and privacy of its patients and clients. The Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires all health-
care providers to inform patients/clients of their Notice of Privacy Practices. It describes our policy and the ways in which we use and protect your personal health information.
I acknowledge that I have been given the opportunity to read Gannett Health Services’ Notice of Privacy Practices either on paper or at www.gannett.cornell.edu.
☛ Signature of patient _______________________________________________________________________________Date (mm-dd-yyyy) __________________________________________
I consent to have Gannett Health Services use and disclose my protected health information for payment, treatment, and health-care operations purposes. My protected health
information means health, billing, and demographic information about me, collected from me, and created or received by Gannett Health Services. In the event that Gannett Health
Services participates with my health insurance, I authorize the payment of benefits to Gannett Health Services.
☛ Signature of patient ___________________________________________________________________________________________________________________________________________
PermISSION tO treatRequires signature of parent/guardian of student under the age of 18.
I give my permission for my daughter/son/ward to receive heath care from Gannett Heath Services and Cayuga Medical Center (and, if necessary, ambulance services) in the event of
an injury or illness. I understand that I will be responsible for all charges for health services provided by Gannett Health Services and by off-campus providers. I acknowledge that I have
been made aware of Gannett’s Notice of Privacy Practices, which can be reviewed at www.gannett.cornell.edu.
☛ Signature of parent/guardian _______________________________________________________________________Date (mm-dd-yyyy) __________________________________________
Alcohol, tobacco, and other drugs
⃞ Alcohol use (#drinks/week _____ )
⃞ Tobacco use (#packs/week ____)
⃞ Other drugs
*
(specify)
⃞ Asthma
⃞ Autoimmune disorder
⃞ Blood disorders, anemia
⃞ Cancer
Cardiovascular disease
⃞ Heart problem
⃞ High blood pressure
⃞ High cholesterol
⃞ Pacemaker
⃞ Eating disorder
Endocrine disorder
⃞ Diabetes
⃞ Thyroid
⃞ Other
*
(specify)
⃞ Eye disease
⃞ Vision deficit
⃞ Gastrointestinal condition
*
(specify)
⃞ Head injury/concussion
⃞ Hearing impairment
⃞ Hepatitis B (acute or chronic)
⃞ Hepatitis C
⃞ HIV
⃞ Hospitalization
*
(specify)
⃞ Kidney disease
⃞ Menstrual disorders
⃞ Mental health disorder
*
(specify)
⃞ Migraine headaches
⃞ Mobility limitations
*
(specify)
Musculoskeletal problems
⃞ Fractures
*
(specify)
⃞ Other
*
(specify)
⃞ Neurologic concerns
⃞ Seizure disorder
⃞ Surgical operations or procedure(s)
*
(specify)
*
Please provide a brief explanation regarding history above. List metal implants, prostheses, and special needs you have. ____________________________________________________
________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________
medIcatIONS(frequent or regular)
⃞ Acne medication
⃞ ADHD medication
⃞ Allergy medication
⃞ Allergy shots
⃞ Antidepressant medication
⃞ Asthma medication
⃞ Birth-control medication
⃞ Blood pressure medication
⃞ Bowel medication
⃞ Headache medication
⃞ Heart-rhythm medication
⃞ Herbal treatments
⃞ Insulin
⃞ Pain medication
⃞ Psychological condition medication
⃞ Seizure medication
⃞ Vitamins
⃞ Other (specify below)
PerSONal HealtH HIStOrY
Check all you have had in the past or have at this time.
Please provide the name, dosage, and indication for the medications you marked above. ____________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________
Part twO: HealtH HIStOrY
PerSONal HealtH care PrOvIder
Name ___________________________________________________________________________________________________________Work Phone ____________________________________
(last, first, middle) (degree/title)
Address _________________________________________________________________________________________________________________________________________________________
Street or P.O. Box
_________________________________________________________________________________________________________________________________________________________________
City State/Province Zip or Postal Code Country
allerGIeS
drug allergies
⃞ No known drug allergies
⃞ Acetaminophen
⃞ Amoxicillin
⃞ Aspirin
⃞ Lidocaine/Xylocaine
⃞ Penicillin
⃞ Sulfa drugs
⃞ Other drug allergy (specify below)
Other allergies
⃞ No known "other" allergies
⃞ Animals
⃞ Foods
⃞ Insect/bee sting
⃞ Latex
⃞ Xray contrast
⃞ Other allergy (specify below)
Please provide a brief explanation of all allergies you indicated above. ___________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________
Part tHree: ImmuNIzatIONS/tb
The following information may be required or recommended for various work settings. If not, it is optional. However, if you have official documentation of your immunization/TB history
and would like it to be part of your Gannett health record, please provide a copy to Gannett Health Services Health Records Office (FAX: 607.255. 0269).
tetanus.must have original series plus a booster within ten years. list dates of all boosters.
•Tetanus/diphtheria/pertussis booster (recommended)Date(mm-dd-yyyy) ____________________________________
•Tetanus/diphtheria boosterDate
(mm-dd-yyyy) ____________________________________
•Tetanus booster Date
(mm-dd-yyyy) ____________________________________
Hepatitis a vaccine ⃞ Havrix ⃞ VAQTA
Date #1
(mm-dd-yyyy) __________________________Date #2 (mm-dd-yyyy) ___________________________
HeP a / HeP b combined vaccine
Date #1 (mm-dd-yyyy) __________________________Date #2 (mm-dd-yyyy) ___________________________ Date #3 (mm-dd-yyyy) ___________________________
Hepatitis b vaccine Series ⃞ Engerix B ⃞ Recombivax-HB
Date #1
(mm-dd-yyyy) __________________________Date #2 (mm-dd-yyyy) ___________________________ Date #3 (mm-dd-yyyy) ___________________________
rabies vaccine
Date #1 (mm-dd-yyyy) ___________________________⃞ RabAvert ⃞ Imovax ⃞ Unknown
Date #2
(mm-dd-yyyy) ___________________________⃞ RabAvert ⃞ Imovax ⃞ Unknown
Date #3
(mm-dd-yyyy) ___________________________⃞ RabAvert ⃞ Imovax ⃞ Unknown
tuberculin (tb) Screening History
check all tuberculin tests that apply.
⃞PPD, Mantoux (skin tests) Date
(mm-dd-yyyy) ________________________Result: ___________mm of induration
⃞T-SPOT®.TB (blood test) Date (mm-dd-yyyy) ________________________Result: ⃞ positive⃞ negative
⃞QuantiFERON®-TB Gold (blood test) Date (mm-dd-yyyy) ________________________Result: ⃞ positive⃞ negative
⃞Chest Xray Date (mm-dd-yyyy) ________________________Result: ⃞ normal⃞ abnormal
⃞History of treatment for Tuberculosis disease
Start Date
(mm-dd-yyyy) ___________________________________________________________________Duration ________________________________
Type of Treatment ________________________________________________________________________________________________________________
⃞History of treatment for positive PPD without disease
Start Date
(mm-dd-yyyy) ___________________________________________________________________Duration ________________________________
Type of Treatment ________________________________________________________________________________________________________________
*If you have never had Tdap, we recommend
you get it now for protection against pertussis,
which is on the rise in New York State.
