Incoming Student Health Form 2014

Student Health Services
900 University Avenue
Riverside, CA 92507
Campushealth.ucr.edu
Incoming Student Health Form
2015-2016 Academic Year
Student Information - Enter the information in this section before printing this form....................................................
Personal Information
Student ID #:
Last Name
First Name
Address
City
Undergraduate
Date of Birth
Age at Enrollment
Country
Zip Code
State
Telephone
Student Status
International Student
Initial
Emergency Telephone
Gender
Qtr/Yr Entering
Graduate
Professional
Tuberculosis Screening Questionnaire (to be completed by the student)
Have you ever had a positive TB skin test?
Yes
No
Have you ever had close contact with anyone who was sick with TB?
Yes
No
Have you ever been vaccinated with BCG (tuberculosis vaccine)?
Yes
No
Were you born in any of the countries listed below and arrived in the U.S. within the last 5 years?
If yes, please CIRCLE the country below.
Yes
No
Have you traveled to/in any of the countries listed below? If yes, please CHECK the country or
countries below.
Yes
No
Afghanistan
Algeria
Angola
Argentina
Armenia
Azerbaijan
Bahrain
Bangladesh
Belarus
Belize
Benin
Bhutan
Bolivia
Bosnia-Herzegovina
Botswana
Brazil
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Central African Republic
Chad
China
Columbia
Comoros
Congo
Cook Islands
Cote d'Ivoire
Croatia
Democratic People's Republic
of Korea
Democratic Republic of Congo
Djibouti
Dominican Republic
Ecuador
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
French Polynesia
Gabon
Gambia
Georgia
Ghana
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
India
Indonesia
Iraq
Japan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgystan
Lao People's Democratic
Republic
Latvia
Lesotho
Liberia
Libyan Arab Jamahiriya
Lithuania
Madagascar
Malawi
Malaysia
Maldives
Mali
Marshall Islands
Mauritania
Mauritius
Micronesia (Federated States)
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nepal
Nicaragua
Niger
Nigeria
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
Sri Lanka
Sudan
Suriname
Swaziland
Syrian Arab Republic
Tajikistan
Thailand
Former Yugoslav Republic of
Macedonia
Timor-Leste
Togo
Tongo
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Republic of Tanzania
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
IF THE ANSWER IS YES TO ANY OF THE ABOVE QUESTIONS, UC RIVERSIDE REQUIRES THAT A LICENSED HEALTHCARE
PROVIDER COMPLETE THE TUBERCULOSIS RISK ASSESSMENT ON THE FOLLOWING PAGE. THE TUBERCULOSIS RISK ASSESSMENT
MAY BE MAILED ALONG WITH PROOF OF IMMUNIZATIONS (THE SUPPLIED FORM OR A COPY OF YOUR OFFICIAL IMMUNIZATION
RECORD).
IF YOU ANSWER NO TO ALL OF THE ABOVE QUESTIONS, PLEASE DISREGARD THE TUBERCULOSIS RISK ASSESSMENT AT THE
BOTTOM OF THE FOLLOWING PAGE.
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