Student Health Services |305 Estill Street Berea, KY 40403| Phone: (859) 985-1415

Welcome to Berea College! We look forward to being your health and wellness partner during your time at Berea!
Student Health Services offers a variety of FREE* medical and dental services to students including:
• Treatment of Acute Illnesses (strep throat, flu, etc.)
• Preventative Health Care
• Treatment of Minor Injuries
• Management of Chronic Conditions (blood pressure monitoring, asthma, diabetes, etc.)
• Preventative Dental Care (cleanings, check-ups/exams, etc.)
• Fillings
Our clinic is located on campus and offers evening and Saturday hours to accommodate student schedules.
Appointments can be scheduled by calling (859) 985-1415.

Berea College requires that specific medical information be on file for each incoming student prior to his or her arrival
on campus. Please know that all information submitted will go to both Berea College and White House Clinics.
These requirements include the following:
• Completed Health History Form
• Tuberculosis Screening Form
• Documentation of Required Immunizations
• Copy of Insurance Card (if covered)

Enclosed please find the health history and tuberculosis screening forms as well as a list of the required immunizations.
Your immunization records can be obtained from your physician, health department, or previous school. Your middle or
high school will almost always have records/documentation of the required immunizations.

You are encouraged to update immunizations before coming to campus. Please consider the recommended
vaccinations when you are updating the required ones. Immunizations covered by insurance now, may not be covered
later when you plan to study abroad or participate in internships. It may be costly to receive the immunizations later.

Students who plan to continue treatment for ADHD with Health Services will need to provide an assessment confirming
the diagnosis from Psychiatrist, Psychologist or other Mental Health Provider. Date of assessment must be within 24
months.

Please email the above information to studenthealth@whitehouseclinics.com. It is important that this information
is received by June 11, 2021. Please send all information together. Failure to supply the required information may
result in delayed residence hall assignments and inability to confirm class registration.

Please note, Berea College will communicate additional changes and/or requirements in regard to COVID-19 closer to
the start of the fall semester. If you have any questions or concerns please contact Jennie Horn, at Berea Primary Care
(859) 985-1415, extension 3007. Thank you for your prompt attention to this important matter.

*Student Health Services are covered by the Health Fee included in each student’s Term Bill.
3/2021
 Student Health Services |305 Estill Street Berea, KY 40403| Phone: (859) 985-1415
Immunization Requirements
All students entering Berea College must demonstrate completion of required immunizations unless they have been
granted prior religious exemption*.

Required Immunizations include:

1. A series of (2) measles, mumps, and rubella (MMR) vaccinations
a. One vaccination after your first birthday
b. The second vaccination must be a minimum of one month later.
2. A primary series of tetanus-diphtheria-pertussis (Tdap) immunization followed by a tetanus
booster (Td or Tdap) within the last 10 years
3. A primary series of polio (IPV) immunizations
4. Meningococcal Immunization (one after age 16)

Varicella, Hepatitis A, and Hepatitis B are highly recommended but not required. Please be aware that insurance
coverage for immunizations changes around ages 18 – 21. Vaccines covered now may not be covered later when they
are needed for study abroad programs or internships.

If you do not have all the required immunizations, you must obtain them before coming to Berea College. If you have
any special circumstances that make it difficult to provide immunization records or you need assistance in obtaining
the vaccines, contact Jennie Horn at Student Health Services by calling (859) 985-1415, extension 3007 or email
studenthealth@whitehouseclinics.com. Failure to supply proof of the required immunization may result in delayed
residence hall assignments and inability to confirm class registration.

Checklist of Information to Return by June 11, 2021

Please submit all materials together.
Email to studenthealth@whitehouseclinics.com

___ Completed Health History ___ Copy of Insurance Card (Front & Back)
___ Tuberculosis Risk Assessment ___ Proof of Required Immunizations
___ Results of TB Skin Test if Answered Yes to Questions 4-12
___ ADHD Assessment (if applicable)**

*Those requesting religious exemption should contact Student Health Services by phone or e-mail to obtain the required documentation form.
Religious exemption status may affect ability to participate in certain international travel opportunities offered by the College. Immunization status
is reviewed prior to clearance for all college-sponsored travel and disease risk for un-immunized travelers is of utmost concern.
**The Assessment must be provided from Psychiatrist, Psychologist or other Mental Health Provider. (Date of assessment must be within 24
months).

3/2021
 Health History Form
Date: _____________________

Patient Information

Name:_______________________________________________________ Date of Birth: ______/________/______

Street:____________________________________ City: _______________ State: ___________ Zip: ______________

Phone: ___________________ Sex: Male Female Other:________________ Marital Status: M S W D

Family Physician: ___________________________________________ Phone: ___________________________

Address:____________________________________ City: _______________ State: ___________ Zip: ____________

Emergency Contact
Name:_______________________________ Relationship: _____________________ Phone: ____________________
Address:__________________________________ City: ________________ State: ___________ Zip: _____________
Allergies
None

Current Medications *If you need more lines, please print a second form.
None
Name of Medication Strength (mg) How Often Reason for Medication

Past Medical History Yes No Yes No Yes No

Acid Reflux Depression Migraines
ADHD Diabetes Peripheral Artery Disease
Anxiety High Blood Pressure Rheumatoid Disease
Asthma High Cholesterol Seizure Disorder
Bipolar Disorder Enlarged Prostate Stroke
Blood Clot (DVT/PE) Heart Attack Seasonal Allergies
Cancer Heart Valve Problem Substance Abuse/Alcoholism
Chronic Pain Hepatitis Thyroid Problem
COPD Hemophilia (Free Bleeder) Tuberculosis
Coronary Artery Disease Kidney Disease Other:
Crohn’s Dis/Ulcerative Colitis HIV/AIDS

Surgical History Year Year

Appendix Removed Hernia Repair (type:_____________________)
Back Surgery Hysterectomy: Partial or Complete
Bladder Surgery Orthopedic Surgery (bones)
Cataract Orthodontic Surgery (teeth)
C Section Tonsils Removed
Ear Tubes Tubal Ligation
Heart Catheterization Vasectomy
Gallbladder Removal Other:
Heart Bypass Other:
Family History: indicate which family members have had the following Other:
None Mother Father Sister Brother Other
Cancer: Type_____________
High Cholesterol
Diabetes Mellitus
Heart Disease
Hypertension
Mental Illness
Stroke
Substance Abuse/Alcoholism
Other: (specify:_______________)
 Health History Form
(continued)

Social History
Do you have children? Yes No Number of Children____ Do you have custody? Yes No

Job Occupation _____________________________________________________________________________ Retired

Disabled If disabled, please list reason:_______________________________________________________

Tobacco Use None Quit (date)___________ Still use: Cigarettes Smokeless/Chew Cigars Pipe

Check the amount of tobacco you use(d) each day. 1/2 pack/can 1 pack/can More

How many years did/have you smoked? ________ 2 packs/cans

Alchol Use None (A drink is 1 shot of liquor, 1 glass of wine, or 1 bottle/can of beer.)

Less than 1 drink/month 1-15 drinks/month 4-14 drinks/week More than 2 drinks/day

Drug Use Yes No Quit (date)_______ If yes, what do you use regularly?_____________________________________

HIV/AIDS Screening Yes No If yes, where and when?_____________________________________________________

Health Maintenance
Do you wear seatbelts? Always Sometimes Never
Have you seen a dentist in the past year? Yes No
Date of your last colonoscopy: ________ Date of your last pneumonia shot: ________
Date of your last tetanus shot: ________ Date of your last shingles shot: ________
Date of your last flu shot: ________ Date of your last eye exam: ________

Women ONLY:
Date of your last mammogram: __________ Date of your last pap smear: __________
Number of pregnancies? __________

Advanced Directives/Living Wills

Do you have an advanced directive or a living will? Yes No
If yes, please give a copy to front desk.
If no, would you like more information? Yes No
Health Insurance Information (Required for all Students)

Although most primary care services are provided at no cost by Student Health Services, the College requires all students
to maintain insurance in case the student’s condition requires additional diagnostic procedures or treatment. Students can
either choose to be covered by a family plan, purchase a plan on healthcare.gov, or purchase the safety net plan offered by
Berea College. Out of state insurances should be verified that coverage extends to Kentucky. Students who need to
purchase coverage through Berea College should respond to emails sent by Financial Aid early in the Fall Term.
Please note: the Berea College safety net plan does not meet minimum required coverage of the Affordable Care Act.
I do not have insurance coverage. I have state Medicaid coverage. If yes, what state?_________________
I have private insurance. Please provide the below information.

Company Name:__________________________________________________________________ Phone: _______________________

Address: ________________________________ City:_______________________ State: ___________ Zip:___________________
Policy Holder: ______________________________________________________ Relationship to Student: _______________________
Coverage to Age: ______________________ Policy #: __________________________ Group: ______________________________
Consent for Treatment (Only Students Less Than 18 Years Old)

Students who will be under 18 years of age at the time of the entrance to Berea College MUST have the following consent
signed by a parent or legal guardian.

I hereby give my permission to White House Clinics for the evaluation and treatment of the medical and dental conditions
of my minor dependent. This includes the administartions of vaccinations or other procedures as determined by the treating
provider. Furthermore, I authorize my minor dependent to seek care and treatment without a parent or guardian present.

Signature of parent or guardian Date