Purdue University Medical History Form - Free Download | Page 2
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Medical History Form 4
Medication Allergies or Intolerances
Past Surgeries (Major and Minor)Signi cant Family Medical History
HEALTHCARE FOR MINORS -- REQUEST & AUTHORIZATION
Please complete the following for students who will be under 18 years of age at the beginning of the school semester:
Pursuant to Indiana Code Paragraph 16-36-1-6 and subject to any limitations listed below, I request and authorize the Purdue
University Student Health Center and/or any community hospitals’ medical personnel, agents, and employees to provide all
reasonably necessary medical care, including but not limited to medical transport, hospital tests, such as pathology, anesthe-
sia, surgery, and prescription drugs advisable for the health of my child. I acknowledge that no representations, warranties,
guarantees as to results or cures will be made.
Student covered by this authorization is _________________________________________________________________
_________________________________________ __________________________________________
Signature of Parent or Legal Guardian / Date
Adult Witness
INTERNATIONAL STUDENTS
Purdue University requires all International Students to purchase the University sponsored health insurance plan unless their
insurance falls into one of the two categories listed below. Failure to purchase medical insurance will result in deregis-
tration from the University.
1. Health insurance sponsored by the government of a student’s home country
2. Health insurance that is provided through a U.S. based employer
International students must have tuberculosis testing done after arriving in the United States. Testing is available at the
Student Health Center, the County Health Department, or through a local, private physician. Documentation of the test being
done within the past three months at another location within the United States may also ful ll this requirement.
MAILING INSTRUCTIONS
Students are encouraged to keep a copy of this form for their personal records.
For additional immunization information, the student may
call the Immunization Of ce of the Health Center at (765) 494-1837.
Due to the large volume of forms received, we regret that we are un-
able to contact individuals submitting incomplete or unsatisfactory immunization information.
This completed Medical History Form should
be returned to:
PURDUE UNIVERSITY STUDENT HEALTH CENTER (PUSH**)
601 Stadium Mall Drive
Immunization Of ce - Room 136
W. Lafayette, Indiana 47907-2052
Form 006 - 4/11
Serious Illnesses/Injuries/Chronic Diseases
Telephone: (765) 494-1837; Fax: (765) 494-1836
INSURANCE INFORMATION
For assistance in ling insurance, the following information is needed. Please note: students should present a current copy of
their health insurance card at each visit to the Student Health Center. Insurance questions should be directed to 765-494-1677.
_____________________________ ____________ Male
Female
Primary Policyholder Yes
No
Name of parent / legal guardian
Date of birth
_____________________________ ____________ Male
Female
Primary Policyholder Yes
No
Name of parent / legal guardian
Date of birth
By signing below, I acknowledge that PUSH** is out-of-network for all health insurance plans except Student Resources Insurance.
_____________________________________ _______________ ______________________________________ _______________
Parent
Date
Student
Date
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