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Medical History/Insurance Information

STUDENTS: This form along with the consent form and immunization record must be completed, submitted, and verified by Health Services. Satisfactory completion of this process is required before you can attend classes.

HEALTH AND IMMUNIZATION FORM INSTRUCTIONS

Welcome to Limestone! We are glad you have chosen us to meet your higher education goals. According to Limestone College policy, a completed Health & Immunization Form is required of all students. We look forward to serving your health care needs while you are a student here. The Health and Immunization Form contains valuable information including medical history, allergies, and immunizations. This information enables us to provide you with the best possible care. Information provided will not affect admission but must be completed and on file in the Health Center before classes begin.

Be certain that your name, date of birth and ID appear on each sheet. The dates of vaccine administration must include the month, day, and year. Please retain a copy for your records.

IMMUNIZATION REQUIREMENTS STATED ON THIS FORM MUST BE COMPLETED AND ON FILE IN THE HEALTH CENTER BEFORE YOU MAY REGISTER FOR CLASSES. 

Failure to meet this requirement may result in a hold on your account and a delay in your ability to register for classes.

CHECKLIST FOR COMPLETING THIS FORM:

  • Medical History Form. Complete and sign consent.
  • Complete and attach a copy of the front and back of your health insurance card.
  • Provide a copy of an official immunization record to include:
  • 2 dates of MMR
  • Tetanus (Tdap) given within 10 years
  • 3 Hepatitis B injections
  • PPD/TB - Tuberculosis questionnaire
  • Meningococcal vaccine: not required, but highly recommended for all incoming students
  • age 21 and under

    Official Immunization Records Include:
  • Personal shot records that are verified by a doctor’s stamp or signature
  • Personal shot records with a clinic or health department stamp
  • Military records or World Health Organization (WHO) documents
  • Previous college or university records that are verified. (Please note that your immunization records do not transfer automatically)

MAIL, FAX, OR EMAIL ADDITIONAL COMPLETED FORMS
Limestone Health Center

1115 College Drive
Gaffney, SC 29340
Fax: (864) 488-8212

Email addresses: healthcenter@limestone.edu
Phone: (864) 488-8348 or (864) 488-4051

Athletes: This form is required IN ADDITION to the forms required by the Athletic Department. Sickle Cell test are to be submitted to the Athletic Department and not the Health Center. Please review your health form to ensure you have completed all pages as instructed. Please retain a copy of all records prior to submitting to the Health Center.

Are you a Limestone Student with a student ID #?*
Are you a Student Athlete? *
Sport:*
Check all that apply
Residency Status*
Full Name (Please enter "none" for middle name if you do not have one) *
Date of Birth*
Home Address*

Parent/ Guardian / Spouse Information

Parent/ Guardian / Spouse Name*
Parent/ Guardian/ Spouse Address (Same as above):*
Parent/ Guardian/ Spouse Address*
Enter "none" if not applicable
Enter "none" if not applicable
Enter "none" if not applicable

Emergency Contact Information

Please list two contacts and two numbers for each contact.

Emergency Contact #1*
Enter "none" if not applicable
Emergency Contact #2
Enter "none" if not applicable

Physician Information

Name of Family Physician
Address

PLEASE READ CAREFULLY


IMPORTANT: Legal safeguards make it necessary for each residential student and student-athlete to have a medical history and immunization record on file in Health Services. The primary purposes of this medical record is to provide a basic point of reference in case of future illness, to identify any medical condition requiring attention before it interferes with your studies or sport activities, and to provide the Health Services Nurse with knowledge of any necessity for ongoing treatment. All information revealed will be considered confidential and will not interfere with acceptance in the College unless such findings would endanger other students or staff. Limestone College is not a record-keeping agency, so please keep a copy of your records for future reference. Incomplete or missing paperwork can cause delays in registration, and/or inability to reserve space in the residence halls.

Insurance Information

 

A copy of this insurance card (front and back) is required if you are insured (see more information at the bottom of the form).

Are you insured? *
Parent (Insured) Name*
Insured's Date of Birth*

Student Medical History

Check all that apply. *
Check all that apply.
  Myself Father Mother Sibling None
Arthritis
Asthma
Blood Disease
Cancer
Chickenpox
Diabetes
Frequent Nosebleeds
Headaches/Migraine
Heart Disease/Attack
Hepatitis
High Blood Pressure
Kidney Disease
Liver Disease
Lung Disease
Measles
Mental Illness
Mumps
Stroke

Current History

By whom were you treated?*
Address:*

Upon submission of this form

You will receive the following documents via email:

  1. Consent Form
  2. Immunization Record

These documents must be completed and returned to the Student Health Center along with a front and back copy of the insurance card (if you are insured).

The email will automatically be sent to the email address above. However, if you would like it to also be delivered to an alternate email address (such as parent or guardian), please enter it below.

Would you like to enter an alternate email address?*
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