WELCOME SEAHAWKS!
On behalf of the Abrons Student Health Center, we are so excited that you are UNCW bound. We lookforward to serving your healthcare needs during your time at UNCW. For information about our services
please visit our website: https://uncw.edu/healthservices.
There are a few things that you can take care of before coming to campus that will make your transition
to UNCW more successful.
1. All incoming first year, transfer, and graduate students are required to show proof ofimmunizations to attend UNCW.
2. All students are also required to have health insurance to attend UNCW. This may be insurance
that students currently have (family, employer, etc.), insurance they purchase through theschool, or a combination of both plans.
Prior to orientation we ask that (1) you send your completed Medical History Form and Immunization
Record to us via mail, email, or fax and (2) that you complete the online insurance waiver or enrollment
process. Directions, with some helpful hints, are located at the end of this letter, along with our address.
You can also find them online at https://uncw.edu/healthservices/shc_newstudents.html
We look forward to meeting you during orientation and to being your doctor’s office away from homewhile you are at UNCW. Please call us at 910-962-3280 if you have any questions.
The Staff of the Abrons Student Health Center
1. MEDICAL HISTORY FORM and IMMUNIZATION RECORD
Students must complete and sign the entire Medical History Form and Immunization Record. If a student
is under the age of 18, a parent or guardian must sign the form as well. If you are having another entity
send in your immunization records, you must also complete, sign, and submit the Medical History Form.
Note that not all your records may be in one place or from one source. Be sure to review what you
are submitting to make sure all requirements are met.
Records of your immunizations may be obtained from any of the following:• Physician or Local Health Department. These records must have a medical provider’s stamp or
signature or have the clinic or health department stamp with address.
• State Immunization Registry printout• Military Records or WHO (World Health Organization) documents. Note that these records maynot contain all the required immunizations.
• Previous High School, College or University recordsMake sure your name and date of birth are on all pages. We encourage you to keep a copy of therecords you submit.
If you are transferring into UNCW, your immunization records do not transfer automatically from othercolleges and universities, you must request that they be sent to the Student Health Center.

You may review North Carolina’s immunization requirements on the Immunization Branch’s website
https://immunize.nc.gov/schools/collegesuniversities.htm.
Important: Immunization requirements must be met within 30 days from the date of the first class(August 24, 2022), or you will be withdrawn from your classes by the registrar without receiving course
credit or monetary refund for classes.
Mail, email, or fax your information to:
University of North Carolina Wilmington
Abrons Student Health Center
601 S. College Road
DePaolo Hall, 2nd Floor
Wilmington, NC 28403

Phone: 910-962-3280
FAX: 910-962-4130
EMAIL: immunizations@uncw.edu

2. HEALTH INSURANCE
Health Insurance is required for all UNCW students. This may be insurance that students currently have(family, employer, etc.), insurance they purchase through the school, or a combination of both plans.
Students are required to waive out of or enroll in the Student Health Insurance Plan via the online web
portal at http://studentbluenc.com/#/uncw each semester.
Students are automatically charged for the Student Health Insurance Plan. Those students who wish towaive out of the insurance, must do so each semester by the deadline, or they will be responsible forthe insurance charge.
To WAIVE (if you have other coverage); Visit: http://studentbluenc.com/#/uncw• New Student Blue User? Click Waive. You will need your Student ID number and current
insurance information, including insurer, phone number, and policy number to complete theprocess. Please use your UNCW email address to waive out of the insurance. Be sure to click
Submit to finalize.
• Your will receive an email that your waiver was approved, denied, or pending. If your waiver isdenied, please review the reason, and resubmit as appropriate. If your waiver is pending, please
continue to check your email for a decision.
• If your waiver is approved, the health insurance charge will be removed from your student
account within 3-7 days.
• Policies must be in effect from September 1, 2022, to December 31, 2022.
To ENROLL (if you DO NOT have other coverage); Visit: http://studentbluenc.com/#/uncw• New Student Blue User? Click on Enroll. You will need your Student ID number and UNCW email
address to set up the account and complete the enrollment process. Please use your mailingaddress that you would like your insurance information mailed to, including cards and refunds.
• You will get an email with the enrollment confirmation number. Save it for your records. YourStudent Blue ID cards will be mailed to the address that you provided. It is that easy!
The cost for the Student Health Insurance Plan in 2021-2022 was $1308.40 per semester, we areawaiting the final cost for 2022-2023. We do not anticipate more than a 3-5% increase in the premium.
Questions? Contact the Student Health Center at 910-962-3280 or Student Blue at 1-888-351-8283.
The deadline to WAIVE or ENROLL is September 12, 2022.

Required Form 1 of 4
601 S. College Road
Wilmington, NC 28403-5985
Ph: 910-962-3280
Fax 910-962-4130
Email: immunizations@uncw.edu

MEDICAL HISTORY FORM (please print)Last NameFirst NameM

To be completed by student

Preferred Name

Permanent Address

DOB (MM/DD/YYYY)

CityHeight:

StateWeight:

Student ID Number (850#)

Zip CodeArea Code/Phone Number☐ F

Sex Assigned by Birth:☐M

Gender identity: ☐ Female ☐ Transfemale/MTF ☐ Male ☐ Transmale/FTM ☐ Non-Binary ☐ Identity (Please state): ___________________Name of Primary Emergency Contact

RelationshipArea Code / Phone Number

Name of Secondary Emergency Contact

RelationshipArea Code / Phone Number

Please provide your current insurance information. In addition, you are required to waive out or enroll in theStudent Health Insurance Plan. Please visit - http://studentbluenc.com/#/uncw

Name of Health Insurance Company

Area Code/Phone Number

Address of Health Insurance Company

Policy Number / Subscriber ID Number

Name of Policy Holder

Relationship of Policy Holder to Student

Please check each item YES or NO, please attach additional information as needed.

Neck injury

Eating disorder

Pain or pressure in chest

Allergy injection therapy

Excessive worry or anxiety

Paralysis

Anemia or Sickle cell anemia

Eye trouble

Pilonidal cyst

AnxietyFrequent or severe headaches

Pneumonia

Arthritis

Frequent vomiting

Protein or blood in urine

AsthmaGallbladder trouble/gallstones

Rectal disease

Bladder infection

Hearing loss

Regular exercise

Blood transfusion

Heart trouble

Rheumatic feverBone, joint or other deformity

HerniaSeasonal allergies

Broken bone (specify)

High blood pressure

Severe menstrual cramps

Cancer (specify)

High cholesterol

Sexually transmitted infection

Chemo/radiation

Hormone therapy

Shortness of breath

Chronic back pain

Intestinal trouble

Skin disease

Chronic coughIrregular periods

Sinusitis

Chronic fatigue

Jaundice or hepatitis

Tobacco use/Vaping

Concussion/Severe head injury

Kidney infection

Thyroid trouble

COVID-19 infection

Kidney stone

UlcerDepression

Knee problems

Wear bicycle helmet

Diabetes

Malaria

Wear contacts/glasses

Dizziness or fainting spells

Mononucleosis

Wear seat belt

MO/YEAR

Drug use

Alcohol use

NO

YES

MO/YEARNO

YES

MO/YEARNOYES

ADD/ADHDRequired Form 2 of 4

MEDICAL HISTORY FORM – continued
Last NameFirst NameM

To be completed by student

Preferred Name

DOB (MM/DD/YYYY)

Student ID Number (850#)

Please check each item YES or NO. Every item checked YES, explain if needed in the appropriate box.

ADVERSE REACTIONS TOYES NOEXPLANATION

Penicillin
Sulfa
Other antibiotics (name)AspirinCodeineOther pain relievers
Other drugs, medicines, chemicals (specify)

YES NOEXPLANATION

Have you had any surgeries? (Include type and year)
Do you have any conditions or disabilities that limit yourphysical activities?
Have you ever been hospitalized?
Has your academic career been interrupted due to physicalor emotional problems?
Is there loss or seriously impaired function of any pairedorgans?
Other than for routine check-ups, have you seen a physician
or health care professional in the past six months?
Any other concerns/items you would like us to know about?

Please send any medical records that may pertain to an item that you reported on this form.
List any drugs, medicines, birth control pills, vitamins, supplements, and minerals (prescription and nonprescription) you use.

Name

DosageFrequency

Name

DosageFrequency

Name

DosageFrequency

Name

DosageFrequency

Name

DosageFrequency

Name

DosageFrequency

IMPORTANT INFORMATION… PLEASE READ CAREFULLY, SIGN, AND DATESTATEMENT BY STUDENT (OR PARENT/GUARDIAN, IF STUDENT IS UNDER AGE 18):
A.

I have personally supplied and reviewed the above information and attest that it is true and complete to the best of my knowledge. I understand that theinformation provided is strictly confidential and will not be released to anyone without my written consent, unless otherwise permitted by law. If I should
become ill or injured or otherwise unable to sign the appropriate forms, I hereby give my permission to the institution to release information from my (ifunder 18 son's/ daughter's) medical record to a physician, hospital or other medical professional involved in providing me (if under 18 my son/daughter)emergency treatment or medical care.

B.

I hereby authorize any medical treatment for myself (if under 18 son/daughter) that may be advised or recommended by the Student Health Center.

C.

I am aware that the Student Health Center charges for some services and that I (if under 18 son/daughter) may be billed through the university student
accounts cashier if the account is not paid at the time of the visit. I (if under 18 son/daughter) accept personal responsibility for settling the account with thecashier and for payment of incurred charges. I am responsible for filing charges with my insurance company and acknowledge that my responsibility to theuniversity is unaffected by the existence of insurance coverage.

SIGNATURE OF STUDENTDATEPRINTED NAME AND SIGNATURE OF PARENT/GUARDIAN, IF STUDENT IS UNDER 18DATERequired Form 3 of 4

IMMUNIZATION REQUIREMENTS
This page provides additional details on the immunizations that are required to attend college in North Carolina. If you arehaving trouble locating your immunization records, the letter that accompanies this packet has suggestions of where tolook or click our website https://uncw.edu/healthservices/shc_newstudents.html. Note that not all your records may be in
one place or from one source. As a reminder, all immunization requirements must be met within 30 days from the first dateof the class or you will be withdrawn from your classes by the registrar without receiving course credit or monetary refund
for classes.

Diphtheria-Tetanus-Pertussis (DTP childhood series) and Tdap (Tetanus-Diphtheria-Pertussis)• All students entering college on or after July 1, 2008, must have had three (3) doses of tetanus/diphtheria toxoid• One dose must be a Tdap
• One dose recommended within the last 10 years

Polio series• Three (3) doses to enter college unless you attained your 18th birthday prior to August 15thMeasles, Mumps, Rubella (MMR) – Live Virus*• 2 MMR vaccines 28 days apart beginning on or after the 1st birthday OR• 2 measles, 2 mumps and 1 rubella single dose OR• Documentation of (+) positive titer• Individuals born before 1957 are not required to have MMR except in case of outbreak

Hepatitis B series• Three (3) doses required if born after July 1, 1994
• Laboratory blood titers are not accepted• Note that HIB is not the same as HEPB

Varicella – Live Virus*• One (1) dose required if born after April 1, 2001, OR• Documented Disease by a provider OR• Documentation of (+) positive titer

COVID-19 Vaccine• While the COVID vaccine is not required to attend UNCW, if you have received a COVID vaccine and/or booster
please submit proof of these with your other vaccination records

TB Skin Test

• Required of International Students from high-risk countries. More information athttps://uncw.edu/healthservices/documents/highrisk_countries_tb_skin_test.pdf* Live Viruses must be given on the same day or 28 days apart, for example, MMR and varicella.

Learn why the American College Health Association recommends these additional vaccines
Meningococcal - https://www.cdc.gov/vaccines/hcp/vis/vis-statements/mening.html
Meningococcal B - https://www.cdc.gov/vaccines/hcp/vis/vis-statements/mening-serogroup.html
HPV - https://www.cdc.gov/vaccines/vpd/hpv/hcp/recommendations.html
Yearly Flu Vaccine - https://www.cdc.gov/flu/prevent/flushot.htm
Physical – Not required for admission into university unless required by your academic programRequired Form 4 of 4

IMMUNIZATION RECORD (please print)
Last NameFirst Name

M

Preferred Name

DOB (MM/DD/YYYY)

Student ID Number (850#)

REQUIRED IMMUNIZATIONSDATE: MM/DD/YYYY

DATE: MM/DD/YYY

DATE: MM/DD/YYYYDTaPTdap

TD

Diphtheria, Tetanus, and Pertussis

Total of three doses required. One MUST be a Tdap.
There may be multiple dates per box.

Polio
MMR (Measles, Mumps, Rubella) OR
Measles
Mumps
Rubella
Hepatitis B
Varicella
OR Verified date of disease

STATUS OF COVID-19 VACCINECOVID-19☐ Declined at this time

Name
Moderna
PfizerJ&J Janssen
Other

RECOMMENDED IMMUNIZATIONS
Meningococcal (ACWY)
Meningococcal B
Human Papillomavirus (HPV)
Tuberculin Skin Test (TST)*Required for International Students

Vaccine

DATE:
MM/DD/YYYY

Vaccine

DATE:
MM/DD/YYYY

Booster

Booster

DATE:
MM/DD/YYYY

DATE:
MM/DD/YYYY

Cervarix
Gardasil
Gardasil-9
Date
IndurationmmIGRA (QuantiFERON orT-SPOT) test

DateResult☐ Positive ☐ Negative

A health care provider MUST SIGN this form, to verify dates.
NAME (please print)
ADDRESS (Business Address or Stamp)

SIGNATURE OF HEALTH CARE PROVIDERDATEAREA CODE/PHONE NUMBER