Purdue University Medical History Form – Fill Out and Use

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

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