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A Place to Distinguish Yourself

Baker is a private, liberal arts university that educates traditional and nontraditional students through small classes, innovative instructors and rigorous coursework.

Where are you taking your classes?

Where do you work?

Student, Faculty & Staff Email Access

Students

Faculty & Staff

Baldwin City Campus
School of Nursing - Topeka Campus
Graduate & Working Adult Campuses - Staff
Graduate & Working Adult Campuses - Faculty
(email ending in @fac.bakerU.edu)

Help Desk

Jobs at Baker University

Baker University is an Equal Opportunity Employer and offers its employees an excellent benefits package.

Teaching Opportunities

Teaching Opportunities at the School of Professional & Graduate Studies

pdf Faculty Application for Graduate School of Education Programs

Career Services

Career Services aids all Baker students and graduates in their search for employment, internships and other academic opportunities.

Career Services

Baker Bookstore

Baker University operates full-service bookstores on its Baldwin City and Overland Park campuses. The bookstores offer textbooks, apparel and gifts. Purchases may also be made online.

Buy or Rent Textbooks

Baldwin City campus

Overland Park campus

Students & Faculty

Use the portal to update personal information, request a receipt or a transcript, access Moodle, enroll in classes and view your schedule.

Welcome to Baker University

Ruth Sarna, RN, Director of Student Health Services

Student Health Services

Ruth Sarna, RN
Director of Student Health Services
785.594.8409
ruth.sarna@bakerU.edu

Sherri Pahcoddy
Coordinator, Student Health Services
785.594.8409
sherri.pahcoddy@bakerU.edu

Flu.gov
Centers for Disease Control & Prevention
Go Ask Alice

Student Life > Health & Counseling > Student Health Center >

Health History Form

Tell us about yourself

*First name:

Middle name:

*Last name:

*Home street address:

*City:

*State:

*ZIP code:

*Home phone:

Cell phone (student):

*Email:

*Date entering Baker:

*Gender:

*Marital status:

*Person to call in an emergency:

*Relationship:

*Phone:

Father's/Guardian's Contact Information

Name:

Address (if different from above):

City:

State:

ZIP code:

Cell phone:

Employer:

Work phone:

Mother's/Guardian's Contact Information

Name:

Address (if different from above):

City:

State:

ZIP code:

Cell phone:

Employer:

Work phone:

Spouse's Contact Information

Name:

Address (if different from above):

City:

State:

ZIP code:

Cell phone:

Employer:

Work phone:

Tell us about your family's health history.

Father's age:

If deceased cause of death and age at death:

Mother's age:

If deceased cause of death and age at death:

Brother's age:

If deceased cause of death and age at death:

Brother's age:

If deceased cause of death and age at death:

Brother's age:

If deceased cause of death and age at death:

Sister's age:

If deceased cause of death and age at death:

Sister's age:

If deceased cause of death and age at death:

Sister's age:

If deceased cause of death and age at death:

Has a parent, brother or sister had any of the following?

Asthma/hay fever
Cancer
Diabetes
Heart trouble
Convulsive disorder
Alcoholism
Hypertension
Tuberculosis
None

Please explain all checked answers:

Insurance Information

*Company name:

*Address:

*City:

*State:

*ZIP code:

*Phone:

*Policy holder name:

*Plan type:

You must submit a copy of your insurance card. Either scan and upload it, or photocopy it and mail it to Student Health Center, PO Box 65, Baldwin City, KS 66006.

Upload a scan of your insurance card in a .jpg, .jpeg, .png, or .pdf format.

Physician's name:

Physician's phone:

*Do you plan to participate in varsity sports?

If yes, what sport?

Student-athletes must complete additional information including a physical examination by a medical doctor before participation is granted by the Athletics Department. Forms are available on the sports medicine page of the BU Athletics website: http://www.bakeru.edu/athletic-department/sports-medicine.

International students are required to purchase a health insurance policy through Baker University when they enroll in classes.

Other:

Other:

Comment on all checked answers.

List all medications you are taking:

List allergies (medicine, food, other):

Immunization Record

Immunity is required prior to registration. You must be in compliance with the immunization requirements to avoid a HOLD on your records at the Office of the University Registrar.

You must submit a copy of your immunization record. Either scan and upload it, or photocopy it and mail it to Student Health Center, PO Box 65, Baldwin City, KS 66006.

Upload a scan of your immunization record in a .jpg, .jpeg, .png, or .pdf format.

Required Immunizations

Meningitis (Menveo or Menactra) Mandatory

Date of immunization (MM/DD/YY):

Waiver of meningococcal meningitis immunization:

I have chosen not to be immunized. Checking this box signifies that I have received and read the material provided to me on meningitis by Baker University. (Checked by parent or guardian if student is under 18.)

MMR (Measles, Mumps, Rubella)

Date of dose 1: Immunized after 12 months of age (MM/DD/YY)*:

Date of dose 2: Immunized at 5 years or later (MM/DD/YY)*:

According to Kansa State Dept. of Health & Environment, all students born after 1957 must have two doses of the measles, mumps and rubella vaccine.

Tetanus-Diptheria (Td or Tdap)

Date of primary series of tetanus-diptheria immunizations completed (MM/DD/YY)*:

Date of tetanus-diptheria booster received in last 5-10 years (MM/DD/YY)*:

Polio

Date of primary series of polio immunizations completed (MM/DD/YY)*:

Recommended Immunizations

Tuberculosis (PPD)

Date of PPD (Mantoux) test within the past year (MM/DD/YY):

PPD results:

If positive, state size of reaction in mm:

If positive PPD, chest x-ray required. Provide date (MM/DD/YY):

X-ray results:

If chest x-ray is positive, please send copy of x-ray report and treatment report to Student Health Center, PO Box 65, Baldwin City, KS 66006.

Date of BCG vaccine (MM/DD/YY):

Date of BCG vaccine (MM/DD/YY): :: Chest x-ray required if PPD not done.

Results:

Hepatitis B

Date of 1st vaccine (MM/DD/YY):

Date of 2nd vaccine (MM/DD/YY):

Date of 3rd vaccine (MM/DD/YY):

Hepatitis A

Date of 1st vaccine (MM/DD/YY):

Date of 2nd vaccine (MM/DD/YY):

HPV Vaccine (Gardasil)

Date of 1st vaccine (MM/DD/YY):

Date of 2nd vaccine (MM/DD/YY):

Date of 3rd vaccine (MM/DD/YY):

Religious or philosophical exemption to immunization requirement:

I (or parent or guardian if student is under 18) object to the immunization of myself to measles, rubella, mumps, diptheria/tetanus, and polio. I understand that exposure to these communicable diseases may cause disabilities and complications. In the event of a measles, rubella, mumps or meningitis outbreak on campus, I will be excluded from campus.

Permission for medical treatment:

Permission is hereby given for treatment in the Baker University Student Health Center and for transportation by ambulance and hospitalization, if needed. (Checked by parent or guardian if student is under 18.)

Clinic & Physician Location & Hours

519 Grove Street (corner of Sixth and Grove)

Monday & Friday
Clinic: 8:30 a.m. – noon, 1 – 4 p.m.

Wednesday
Clinic: 8:30 – 9:30 a.m., 1 – 4 p.m.
Closed midmorning for staff meetings

Tuesday
Clinic: 8:30 a.m. – noon, 1 – 4 p.m.

Thursday
Clinic: 8:30 – 11:30 a.m., 12:30 – 4 p.m.
Physician: 12:30 – 4 p.m.

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