Medical History Form
Seizures: Yes No Comments: ___
Chronic Diseases: ___
Allergies: ___
Drug Allergies: ___
Medications: ___
Significant Historical Information: ___
IMMUNIZATIONS:
We recommend a certificate from a doctor's office/clinic as proof of immunization.
- Tdap (tetanus/diphtheria/pertussis): Recommended within the last ten years.
- Polio Series: Recommended if student is 18 years or younger.
- Mumps: Recommended immunization if no history of illness.
- Measles (rubelola): Recommended documentation of two MMR vaccines. Either a certificate of immunization dated 1969 or later or proof of positive titer suggested. Copy of lab report may be submitted. History of illness is not sufficient.
- Tuberculin Skin Test: Recommended within six months prior to start of class. The documentation should state the test results were negative or positive. CHEST XRAY IS STRONGLY RECOMMENDED EVERY YEAR IF TUBERCULIN SKIN TEST WAS REPORTED POSITIVE.
- Menactra / Meningitis: Vaccine is recommended for all incoming new students up to age 26. Vaccine is also recommended for older or transferring students living on campus.
- Varicella (chickenpox): Recommended to have two vaccines or history of the chickenpox disease prior to starting KSU.
HEALTH HISTORY AND PHYSICAL ASSESSMENT
Students who submit the health history form or copy of past immunizations will be notified of the immunizations that need to be updated prior to the start of class. Students should submit the health history form completed by a doctor's office or clinic within the past six months.
Rev 2/22/16