Serogroups 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.

QuestionAnswer
Form NamePurdue University Medical History Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesderegistration, Rubeola, serogroups, Meningococcal

Form Preview Example

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 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

A

MMR - Measles, Mumps, Rubella

E

 

Two (2) doses required

1. _____/_____/_____

 

 

after 1st birthday and

 

2. _____/_____/_____

 

 

after 1968

 

 

 

 

 

 

 

 

 

 

 

Section B required only if

you did not complete section A

 

B

 

 

Measles (Rubeola) 2 doses after 1st birthday

 

 

_____/_____/_____

& _____/_____/_____

 

 

or titer* _____/_____/_____

 

 

Mumps - 1 dose after 1st birthday

F

 

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

 

 

 

Rubella - 1 dose after 1st birthday

 

 

_____/_____/_____

or titer*_____/_____/_____

 

*- 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 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

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 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)

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 765-494-1677.

____________________________________

_______________

Male

Female

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.

_____________________________________

_______________

___________________________________

_______________

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 student-insurance@purdue.edu or 765-496-3998.

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) 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:

PURDUE UNIVERSITY STUDENT HEALTH CENTER (PUSH**)

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