[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-0-en-105":3,"doc-seo-429830-105":59,"doc-detail-429830-en":130},{"code":4,"msg":5,"data":6},0,"success",[7,13,18,23,28,33,38,43,48,51,55],{"id":8,"doc_module":4,"doc_module_name":9,"category_name":10,"show_sort_weight":11,"slug":12},1,"Document","Story & Novel",90,"story-novel",{"id":14,"doc_module":4,"doc_module_name":9,"category_name":15,"show_sort_weight":16,"slug":17},2,"Literature",80,"literature",{"id":19,"doc_module":4,"doc_module_name":9,"category_name":20,"show_sort_weight":21,"slug":22},4,"Exam",70,"exam",{"id":24,"doc_module":4,"doc_module_name":9,"category_name":25,"show_sort_weight":26,"slug":27},5,"Comic",60,"comic",{"id":29,"doc_module":4,"doc_module_name":9,"category_name":30,"show_sort_weight":31,"slug":32},6,"Technology",50,"technology",{"id":34,"doc_module":4,"doc_module_name":9,"category_name":35,"show_sort_weight":36,"slug":37},7,"Healthcare",40,"healthcare",{"id":39,"doc_module":4,"doc_module_name":9,"category_name":40,"show_sort_weight":41,"slug":42},8,"Research & Report",30,"research-report",{"id":44,"doc_module":4,"doc_module_name":9,"category_name":45,"show_sort_weight":46,"slug":47},9,"Religion & Spirituality",20,"religion-spirituality",{"id":46,"doc_module":4,"doc_module_name":9,"category_name":49,"show_sort_weight":46,"slug":50},"World Cup","world-cup",{"id":52,"doc_module":4,"doc_module_name":9,"category_name":53,"show_sort_weight":52,"slug":54},10,"Lifestyle","lifestyle",{"id":56,"doc_module":4,"doc_module_name":9,"category_name":57,"show_sort_weight":24,"slug":58},19,"General","general",{"code":4,"msg":60,"data":61},"ok",{"site_id":62,"language":63,"slug":64,"title":65,"keywords":66,"description":67,"schema_data":68,"social_meta":123,"head_meta":125,"extra_data":127,"updated_unix":129},105,"en","xavier-university-risk-management-insurance-hhf-201-student-health-history-form-all-overnight-travel-domestic-and-international","XAVIER UNIVERSITY - RISK MANAGEMENT & INSURANCE - HHF 201 Student Health History Form - All Overnight Travel - Domestic and International","","Student Health History Form (HHF 201) for Xavier University covers general information, gender selection, and contact address details. The form collects health problems, drug allergies and reactions, and all regularly taken medications. It requests medical history items to be checked (e.g., anemia, asthma, arthritis, kidney/bladder issues, cancer, epilepsy, high blood pressure, ulcer/inflammatory bowel disease, heart problems, migraines, eating disorders, psychosis/schizophrenia, anxiety/depression, substance abuse, surgery, or none) with explanations when applicable. It also includes tuberculosis exposure questions, TB skin test status, any TB medicines taken, family medical history, and an authorization for emergency medical care release to healthcare personnel.",{"@graph":69,"@context":122},[70,84,105],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/xavier-university-risk-management-insurance-hhf-201-student-health-history-form-all-overnight-travel-domestic-and-international/429830/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/xavier-university-risk-management-insurance-hhf-201-student-health-history-form-all-overnight-travel-domestic-and-international/429830.png","ImageObject",300,407,{"name":92,"@type":93},"Theodore","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-10-30","2026-09-29",true,{"@type":102,"interactionType":103,"userInteractionCount":52},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"What information must be provided in the form’s general section?","Question",{"text":112,"@type":113},"The form requests participant gender selection and identifying and contact details including name, birth date, permanent mailing address, and telephone.","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"How should students report health problems, drug allergies, and medicines?",{"text":117,"@type":113},"Students list continuing health problems, specify drug allergies and reactions (or write “none” if not applicable), and record all regularly taken medicines (including prescriptions and over-the-counter options, or “none”).",{"name":119,"@type":110,"acceptedAnswer":120},"What authorizations and acknowledgements are included before submission?",{"text":121,"@type":113},"The participant authorizes Xavier to release information from the form to medical personnel for emergency care related to the overnight travel experience, states the information won’t be used for other purposes like assessing fitness, and certifies accurate completion by signing and dating.","https://schema.org",{"og:url":83,"og:type":124,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":126,"canonical":83},"index,follow",{"doc_id":128,"site_id":62},429830,1791115011,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":92,"user_avatar":133,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":52,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":14,"language":139,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":140,"faqs":141,"seo_title":142,"seo_description":67,"update_tm":143,"read_time":24,"preview_page_count":4},7971461740886,"https://ap-avatar.wpscdn.com/davatar_3d24733baf745e90a7e4bdd5f77d97b2","XAVIER UNIVERSITY – RISK MANAGEMENT & INSURANCE Rev. 10/1/2017  \nHHF 201 Student Health History Form – All Overnight Travel – Domestic and International  \nSTUDENT HEALTH HISTORY FORM  \nGeneral Information:  \n  ( ) Male ( ) Female  \n(LASTNAME) (FIRST) (MIDDLE) (BIRTH DATE)  \nPermanent Mailing Address:  \n(STREET) (CITY) (STATE) (ZIP CODE) (TELEPHONE)  \nHealth Problems: I have the following health problems [list any continuing health problems; write “none” if not applicable]:    \n____________________________________________________________________  \nDrug Allergies and Reaction: I have the following drug allergies and reactions [list any drug allergies and briefly describe what happened; write “none” if not applicable]:    \n_________________________________________  \nMedicines: I regularly take the following medicines [include any pills or injections, prescription and over-thecounter medications; write “none” if not applicable]:    \nMedical History: I have had the following [check if you have ever had any of the following and explain below] :  \n Anemia  \n Asthma or Allergies  \n Arthritis or Back problems  \n Bladder or Kidney problems  \n Blood Clot(s) or bleeding problems  \n Cancer or Leukemia  \n Epilepsy, Seizure Disorder or Syncope (Fainting)  \n High Blood Pressure  \n Ulcer or Inflammatory Bowel Disease  \n Heart Problems  \n Migraine headache  \n Eating Disorder  \n Psychosis or Schizophrenia  \n Anxiety or Depression  \n Substance Abuse  \n Surgery  \n None of the above  \nIf you checked any of the above, please provide a brief explanation:    \n_________________________________________________________________________________________  \n_________________________________________________________________________________________  \nHave you ever lived in close contact with anyone who had tuberculosis? Yes No  \nThis is the only form approved by Xavier University for this purpose. It may not be modified or changed in any way.  \n1 of 2  \nXAVIER UNIVERSITY – RISK MANAGEMENT & INSURANCE Rev. 10/1/2017  \nHHF 201 Student Health History Form – All Overnight Travel – Domestic and International  \nTB skin test:   negative   year  \n  positive   year  \n  never tested  \nTB Medicines Taken:  \n_______________________________________________________  \nFamily Medical History [check if anyone in your family has have ever had any of the following health problems]:  \n Blood Clots or Bleeding Problems  \n Cancer  \n Diabetes  \n Heart Disease  \n Sickle Cell Disease  \nPlease use the space provided to inform us if there is anything else that is not covered by this form that we should be aware of:    \n_______  \n______________ ______________________________________________________  \n* * * * * * * *  \nIn the event I require emergency medical care in connection with my participation in an overnight travel experience, I authorize Xavier to release the information provided on this form to medical personnel to facilitate that medical care. Xavier will not use the information disclosed on this form for any other purpose, including any assessment of my ability or fitness to participate in an overnight travel experience.  \nBy signing below, I certify that I have accurately provided my health history information above.  \nParticipant’s Signature Date  \nBanner ID:    \nThis is the only form approved by Xavier University for this purpose. It may not be modified or changed in any way.","cbCainydbpN0HVXS","https://ap.wps.com/l/cbCainydbpN0HVXS","pdf",82577,"English","# General Information\n## Health Problems and Allergies\n## Medicines and Medical History\n## Tuberculosis and TB Treatment\n## Family Medical History\n## Emergency Authorization and Signature","[{\"question\":\"What information must be provided in the form’s general section?\",\"answer\":\"The form requests participant gender selection and identifying and contact details including name, birth date, permanent mailing address, and telephone.\"},{\"question\":\"How should students report health problems, drug allergies, and medicines?\",\"answer\":\"Students list continuing health problems, specify drug allergies and reactions (or write “none” if not applicable), and record all regularly taken medicines (including prescriptions and over-the-counter options, or “none”).\"},{\"question\":\"What authorizations and acknowledgements are included before submission?\",\"answer\":\"The participant authorizes Xavier to release information from the form to medical personnel for emergency care related to the overnight travel experience, states the information won’t be used for other purposes like assessing fitness, and certifies accurate completion by signing and dating.\"}]","XAVIER UNIVERSITY - RISK MANAGEMENT & INSURANCE - HHF 201 Student Health History Form - All Overnight Travel - Domestic and International | PDF",1790651304]