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.
Question | Answer |
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Form Name | Purdue University Medical History Form |
Form Length | 2 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 30 sec |
Other names | deregistration, Rubeola, serogroups, Meningococcal |
PURDUE UNIVERSITY STUDENT HEALTH CENTER
MEDICAL HISTORY FORM
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
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
A |
MMR - Measles, Mumps, Rubella |
E |
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Two (2) doses required |
1. _____/_____/_____ |
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after 1st birthday and |
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2. _____/_____/_____ |
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after 1968 |
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Section B required only if |
you did not complete section A |
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B |
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Measles (Rubeola) 2 doses after 1st birthday |
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_____/_____/_____ |
& _____/_____/_____ |
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or titer* _____/_____/_____ |
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Mumps - 1 dose after 1st birthday |
F |
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_____/_____/_____ or titer*_____/_____/_____ |
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Rubella - 1 dose after 1st birthday |
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_____/_____/_____ |
or titer*_____/_____/_____ |
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*- Lab copy required
CTetanus/Diphtheria
Must have had a booster Td within last ten (10) yrs: Tetanus/diphtheria _____/_____/_____ or
Tetanus/diphtheria/Pertussis _____/_____/_____
DAllergies
Please list medication allergies or intolerances
____________________________________
_____________________________________ ______________
Hep B
___/___/___ ___/___/___ ___/___/___
Meningococcal Vaccine ___/___/___
Gardasil
___/___/___ ___/___/___ ___/___/___
Cervarix
___/___/___ ___/___/___ ___/___/___
AUTHORI ZATI ON TO TREAT STUDENTS
UNDER THE AGE OF 18
Please complete the following for students who will be under age 18 at the beginning of the semester:
Pursuant to Indiana Code Paragraph
________________________________ |
__________ |
Signature of Parent or Legal Guardian |
Date |
____________________________________ |
___________ |
Adult Witness |
Date |
Signature of healthcare records keeper |
Date |
(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
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) |
Date |
I NSURANCE I NFORM ATI ON
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
____________________________________ |
_______________ |
Male |
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Female |
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Name of primary policyholder |
Date of birth |
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By signing below, I acknowledge that PUSH** is
_____________________________________ |
_______________ |
___________________________________ |
_______________ |
Parent |
Date |
Student |
Date |
I NTERNATI ONAL STUDENTS
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
M AI LI NG I NSTRUCTI ONS
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)
PURDUE UNIVERSITY STUDENT HEALTH CENTER (PUSH**)
601 Stadium Mall Drive
Immunization Offi ce - Room 137 W. Lafayette, Indiana
Form 006 - 5/14
Telephone (765)