Medical History Form

MEDICAL HISTORY FORM

SECTION I

_

LAST/FAMILY NAME

FIRST/GIVEN NAME

MI

U#

STREET ADDRESS

PHONE NUMBER

CITY, STATE, ZIP, COUNTRY

EMAIL ADDRESS

DATE OF BIRTH (MM/DD/YYYY)

GENDER

Male

Female

/ / _

ENTERING SEMESTER

Fall

Spring

Summer

Year

Indeterminate

COUNTRY OF ORIGIN

USA

Other country, specify

:

HISPANIC ORIGIN

Yes

No

RACE

African American

American Indian

Asian/Pacific Islander

White

Other

Per Florida Rule 6C‐6.001, my signature below signifies that the information provided in Sections I through VI herein, including my medical history, is true

and complete, to the best of my knowledge. I further acknowledge receipt and understanding of the immunization information provided.

Signature

Date

DISLAIMER/NOTICE: Information collected on this form is for registration purposes only and does not create a medical record and is not reviewed by medical personnel.

Should you become a SHS patient, this document may be retrieved to expedite initial medical appointment and may become part of your medical record.

SECTION II ‐ IMMUNIZATION HISTORY

(Sections A, B, and C must be completed OR supporting documentation provided, as detailed in the Medical History Form Instructions, and is a requirement for registration.)

A.

Measles/Mumps/Rubella (Select 1 of the following):

Measles (Rubeola)‐dates of 2 doses OR copy of lab titer (IgG)

I was born before

M MR (Measles/Mumps/

12/31/1956

Measles #1

Rubella) dates of 2 doses

therefore

this

OR Copy of Lab Titer & Date

MMR #1

vaccination

Measles #2

requirement does not

MMR #2

Rubella (German Measles)‐date of dose OR copy of lab titer (IgG)

apply to me.

Rubella #1

OR Copy of Lab Titer & Date

B.

Meningitis Vaccine (Select 1 of the following):

RESIDENTIAL STUDENTS NOTE: This is a requirement for all students who will live on the

USF campus. No student will be assigned a USF residence hall room until proof of meningitis

Date of vaccination:

vaccination is received by USF Student Health Services.

I will not be living on campus and decline receipt of the Meningitis vaccine.

C. Hepatitis B Vaccine (Select 1 of the following):

Dates of vaccination:

Hep B #1

Hep B #2

Hep B #3

I decline receipt of the Hepatitis B vaccine.

D. Tetanus/Diphtheria (Optional ‐ not required for enrollment; only for medical purposes.)

Date of vaccination:

Tdap

Td

E. An official stamp from a doctor’s office, clinic, or Health Department AND an authorized signature must appear on this form or on the

official document(s) attached in order to be accepted:

______________________

Name and address of clinic OR Physician (Facility) Stamp

Authorized Signature & Date

Mail your completed form and any copies of records or lab reports, if applicable, to the campus where you will be attending class.

Tampa Campus & St. Petersburg Campus

Polytechnic Campus

Sarasota Campus

4202 East Fowler Avenue, SHS100

3433 Winter Lake Road – Student Affairs

Counseling & Wellness Center –CWC 120

Tampa, FL 33620‐6750

Lakeland, FL 33803

5805 Bay Shore Road

Phone: (813) 974‐4056

Phone: (863) 667‐7000

Sarasota, FL 34243

Fax: (813) 974‐5888

Fax: (863) 667‐7096

Phone: (941) 487‐4254

Email: immunization@shs.usf.edu

Fax: (941) 487‐4256

Email:

immunization@poly.usf.edu