Purdue University Medical History Form PDF Details

The Purdue University Medical History Form is a form used to record a patient's medical history. The form is used to document the patient's medical history, including any allergies, current medications, and past surgeries. The form also includes information on the patient's family medical history. The Purdue University Medical History Form is a valuable resource for healthcare providers.

You will discover details about the type of form you want to prepare in the table. It will tell you just how long it will take to finish purdue university medical history form, exactly what parts you need to fill in and a few additional specific details.

Form NamePurdue University Medical History Form
Form Length2 pages
Fillable fields0
Avg. time to fill out30 sec
Other namesMeningococcal, deregistration, ELISA, titer

Form Preview Example



1.Please PRINT - This form must be completed in English

2.The only requirement of those born before 1957 is to have had a booster of Tetanus/diphtheria (Td) in the last 10 years

3.Requests for a medical or religious exemption must be submitted to the Health Center Director and signed by the student (parent/guardian only if the student is under the age of 18, and co-signed by the student)

Last Name _____________________________First __________________________ Middle ________________

Purdue ID # ___________________________Date of Birth _____________ International Domestic 

Emergency contact name and phone # ____________________________________________________________

Important: include MONTH / DAY / YEAR in all answers (example: 11 / 11 / 1993 ) Section E vaccines recommended, but not required


MMR - Measles, Mumps, Rubella



Two (2) doses required

1. _____/_____/_____



after 1st birthday and


2. _____/_____/_____



after 1968












Section B required only if

you did not complete section A





Measles (Rubeola) 2 doses after 1st birthday




& _____/_____/_____



or titer* _____/_____/_____



Mumps - 1 dose after 1st birthday



_____/_____/_____ or titer*_____/_____/_____




Rubella - 1 dose after 1st birthday




or titer*_____/_____/_____


*- Lab copy required


Must have had a booster Td within last ten (10) yrs: Tetanus/diphtheria _____/_____/_____ or

Tetanus/diphtheria/Pertussis _____/_____/_____


Please list medication allergies or intolerances


_____________________________________ ______________

Hep B

___/___/___ ___/___/___ ___/___/___

Meningococcal Vaccine ___/___/___


___/___/___ ___/___/___ ___/___/___


___/___/___ ___/___/___ ___/___/___



Please complete the following for students who will be under age 18 at the beginning of the semester:

Pursuant to Indiana Code Paragraph 16-36-1-6 and subject to anylimitationslistedbelow,IrequestandauthorizethePurdue University Student Health Center and/or any com- munity hospitals’ medical personnel, agents, and em- ployees to provide all reasonably necessary medical care, including but not limited to medical transport, hospital tests, such as pathology, anesthesia, 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.



Signature of Parent or Legal Guardian




Adult Witness


Signature of healthcare records keeper


(parent or guardian) or medical provider required

Please also complete back side of form

M ENI NGOCOCCAL DI SEASE - All students must read and sign below:

Meningitis is an inflammation of the lining surrounding the brain and spinal cord. For most college students, the risk of menin- gococcal 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 meningococcal disease relative to other persons their age. Lifestyle 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) 494-1818.

By signing below, I acknowledge that I have reviewed the above information regarding meningococcal meningitis.



Student (or parent if student is under 18 yrs of age)



For assistance in fi ling insurance, the following information is needed. Please note: students should present a copy of their current insurance card at each visit to the Student Health Center. Insurance questions should be directed to 765-494-1677.





Name of primary policyholder

Date of birth




By signing below, I acknowledge that PUSH** is out-of-network for all health insurance plans except Student Resources Insurance.










Purdue University requires all International Students to purchase the University sponsored health insurance plan. Failure to purchase medical insurance will result in a $200 late fee and a hold will be placed on your account to prevent fu- ture class registration. Note: Students should purchase the insurance plan before receiving the Tdap and/or MMR vaccina- tion or the mandatory TB test to have the cost covered by the plan.

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 fulfi ll this requirement.

Waivers are granted only when specifi c criteria are met. For complete information about the required insurance plan and waivers, please visit our Student Insurance pages at www.purdue.edu/push.

Student Insurance Questions may be directed to student-insurance@purdue.edu or 765-496-3998.


Students are encouraged to keep a copy of this form for their personal records. For additional immunization information, the student may call the Immunization Offi 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. Please return completed form to:


601 Stadium Mall Drive

Immunization Offi ce - Room 137 W. Lafayette, Indiana 47907-2052

Form 006 - 5/14

Telephone (765) 494-1837 Fax (765) 494-1836

How to Edit Purdue University Medical History Form Online for Free

This PDF editor enables you to fill in documents. You don't have to undertake much to change serogroups files. Basically stick to the next steps.

Step 1: Step one will be to click the orange "Get Form Now" button.

Step 2: After you've entered the titers editing page you may discover the different actions you'll be able to perform with regards to your template from the upper menu.

The particular sections will make up the PDF document:

recordkeeper blanks to complete

The application will require you to complete the Two doses required after st, Meningococcal Vaccine, Hep B, Section B required only if you did, Measles Rubeola doses after st, or titer, Gardasil, Cervarix, Mumps dose after st birthday, F titer, Rubella dose after st birthday, titer, Lab copy required, TetanusDiphtheria Must have had a, and AUTHORI ZATI ON TO TREAT STUDENTS field.

part 2 to completing recordkeeper

The program will ask you for data to instantly complete the section TetanusDiphtheria Must have had a, TetanusdiphtheriaPertussis, Allergies Please list medication, Signature of healthcare records, Pursuant to Indiana Code Paragraph, Signature of Parent or Legal, Adult Witness Date, and Please also complete back side of.

stage 3 to finishing recordkeeper

The By signing below I acknowledge, Student or parent if student is, I NSURANCE I NFORM ATI ON, For assistance in fi ling insurance, Name of primary policyholder, Male Female, By signing below I acknowledge, Parent, Date, Student, and Date section is the place to insert the rights and obligations of both parties.

step 4 to completing recordkeeper

Step 3: Select the Done button to ensure that your finalized file can be exported to any type of gadget you decide on or sent to an email you indicate.

Step 4: It can be better to save duplicates of your document. You can be sure that we will not disclose or view your particulars.

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