Purdue University Medical History Form - Free Download
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Purdue University Medical History Form
Medical History Form 4
PURDUE UNIVERSITY STUDENT HEALTH CENTER
1. Please PRINT - This form must be completed in English and signed by (1) a medical provider or personal recordkeeper, and
(2) the student (parent or guardian if student is under age 18)
2.
Individuals born before 1957 are considered immune to measles, mumps and rubella, but a booster of Tetanus/diphtheria (Td)
must have been received in the last 10 years
3. All immunizations must have been received after 1968
4. Individuals seeking a medical or religious exemption must submit a letter of request to the Director of the Student Health Center
signed by the student (parent/guardian if student is under the age of 18)
MMR - Measles, Mumps, Rubella
Two (2) doses required
after 1st birthday
Important: include MONTH / DAY / YEAR in all answers (example: _____/_____/_____ )
Measles (Rubeola) 2 doses after 1st birthday
_____/_____/_____ _____/_____/_____
_____/_____/_____
_____/_____/_____
Section B. required only if you did not complete section A.
or date of disease or titer**
Mumps - 1 dose after 1st birthday
_____/_____/_____
_____/_____/_____ or
Rubella* - 1 dose after 1st birthday
* - Disease not accepted as proof of immunity for rubella
** - Lab copy required - acceptable titers are ELISA or RHA
Must have had a booster Td within last ten (10) years
or Tdap
MEDICAL HISTORY FORM
Last Name:_____________________________First: __________________________ Middle:________________
Purdue ID #: ________________________ Date of Birth: _____________ International Domestic
Emergency contact name and phone #:____________________________________________________________
4
1988
A.
_____/_____/_____
Meningitis is an in ammation of the lining surrounding the
brain and spinal cord.
For most college students, the risk of
meningococcal disease is similar to that of persons the same
age in the general population.
For college freshmen who live
in residence halls, there is a modestly increased risk of menin-
gococcal disease relative to other persons their age.
Life-
style behaviors that put individuals at increased risk include
cigarette smoking, alcohol ingestion, bar patronage, and close,
crowded living conditions.
Meningococcal vaccine is reasonably safe and effective against
the serogroups included in the vaccine.
Approximately 70% of
meningococcal disease is caused by serogroups covered by the
vaccine.
Protective levels of antibody usually are achieved 7-
10 days after vaccination.
The Purdue Student Health Center
stocks and administers the vaccine.
For further information,
please call (765) 494-1837.
Signature of healthcare recordkeeper Date
By signing below, I acknowledge that I have reviewed the
above information regarding meningococcal meningitis.
Signature of student (parent/guardian if under age 18) Date
Hep B
Meningococcal Vaccine ___/___/___
___/___/___ ; ___/___/___ ; ___/___/___
11
1.
2.
Tetanus/Diphtheria
_____/_____/_____ & _____/_____/_____
_____/_____/_____
C.
Section D. required ONLY for international students
TB Test
Results: (in mm) ____
must be administered in the U.S. within previous 3 months
___/___/___
B.
D.
E.
Section E. vaccines recommended, but NOT required
Gardasil
___/___/___ ; ___/___/___ ; ___/___/___
All students must read and sign below:
or date of disease or titer**
_____/_____/_____ _____/_____/_____
titer**
_____/_____/_____
Please also complete back side of form
Cervarix
___/___/___ ; ___/___/___ ; ___/___/___
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