Medical Health History Form Page 2
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2Health Information: (cont.)
Current Medications:___________________________________________________________________________________________
___________________________________________________________________________________________________________
Allergies (medicine, food, other):__________________________________________________________________________________
___________________________________________________________________________________________________________
Tuberculosis (TB) Screening
The state of Kansas requires each incoming university student (freshman and transfer) to complete the TB (tuberculosis) screening.
Please complete the four questions below.
1. Have you ever had a POSITIVE TB (tuberculosis) skin test?
Yes
No
2. Have you lived with, or had close contact with anyone who was sick with tuberculosis?
Yes
No
3. Were you born in a country other than the United Sates?
Yes
No
If yes, country_______________________________________
4. Have you traveled or lived 3 consecutive months in any country other than the United States?
Yes
No
If yes, country_______________________________________
To review the at-risk countries go to
Immunization Record:
(Please attach a copy of immunizations) .
Baker University requires students, regardless of age, to submit a copy of their updated immunization records. This documentation can
be a personal immunization record signed by a health care provider, a physician or clinic report stating all immunization records or a
copy of school immunization records. It must include the 4 REQUIRED immunizations.
1. MMR (Measles, Mumps, Rubella) immunization. Two doses required at least 28 days apart for students born after 1956.
2. Tdap (Tetanus, Diphtheria, and Pertussis) immunization booster within the last 10 years.
3. Meningitis (MCV4) immunization. Two doses of MCV4 are recommended. If the first dose is given before the 16th birthday,
then a booster is required.
4. Polio series completed. Primary series, doses at least 28 days apart. Three primary series are acceptable.
Waiver of Meningococcal Meningitis Immunization: (Does NOT receive vaccination)
I have chosen NOT to be immunized for Meningitis. My signature below signifies that I understand I will be removed from
housing and not allowed to attend classes, in the event of a Meningitis outbreak on campus.
Signature of Student Required (if waiving vaccine) _______________________________________ Date_______________________
(Parent/Guardian if student is under 18)
Religious/Philosophical Exemption to Immunization Requirement:
I object to the immunization to measles, mumps, rubella, diphtheria/tetanus, polio. It is understood that exposure to these
communicable diseases may cause disabilities and complications. My signature below signifies that I understand I will be
removed from housing and not allowed to attend classes, in the event of measles, mumps, rubella or meningitis outbreak on
campus
.
Signature of Student Required (if waiving vaccinations) _____________________________________ Date_____________________
(Parent/Guardian if student is under 18)
PERMISSION FOR MEDICAL TREATMENT
Permission is hereby given for treatment in the Baker University Student Health Center and for transportation by ambulance, if
needed.
Signature of Student________________________________________________________________Date______________________
(Parent/Guardian if student is under 18)
Office Use Only:
Meningitis
Hepatitis B
❍ #1 _____________, _____ ❍ #2 _____________, _____
❍ #1 ____________ ❍ #2 ____________ ❍ #3 ____________
MM
DD
YY
AGE
MM
DD
YY
AGE
MM
DD
YY
MM
DD
YY
MM
DD
YY
MMR (Measles, Mumps, Rubella)
Hepatitis A
❍ #1 ____________ ❍ #2 ____________
❍ #1 ____________ ❍ #2 ____________
MM
DD
YY
MM
DD
YY
MM
DD
YY
MM
DD
YY
Polio
HPV Vaccine (Gardasil):
❍ Series Completed _____________
❍ #1 ____________ ❍ #2 ____________ ❍ #3 ____________
MM
DD
YY
MM
DD
YY
MM
DD
YY
MM
DD
YY
Tdap (Tetanus)
Varicella:
Date of Disease
❍ Series Completed _____________ ❍ Within 10 yrs _____________
❍ #1 ____________ ❍ #2 ____________ ❍
____________
MM
DD
YY
MM
DD
YY
MM
DD
YY
MM
DD
YY
MM
DD
YY
9/20/16
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