Schreiner University Health History Form
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3HEALTH AND WELLNESS CENTER . SCHREINER UNIVERSITY . CMB 6250 . 2100 MEMORIAL BLVD . KERRVILLE, TX 78028-5697
Office Use Only: ID#___________________
Verified Resident
Verified Commuter
Mandatory Ins. Requirement
M.V. Received
20__ Ins. Waiver Met #_________
M.V. Entr’d: _________ By____
20 __ Ins. Waiver Met #_________
HHF Rec’d/H&W:
20 __ Ins. Waiver Met #_________
HHF Entr’d:__________
20 __ Ins. Waiver Met #_________
By____
20__ Ins. Waiver Met#__________
SCHREINER UNIVERSITY HEALTH HISTORY FORM
Imm. Rec’d/H&W
Meningitis vaccination verification, other required immunization records and the Health History Form must be on file in Health Center 15 DAYS
PRIOR to start of classes to allow time for processing. Mail forms to address above or fax to (830)792-7304.
(Please retain original documents for your files.)
Check ALL that apply:
UNDERGRADUATE STUDIES
ATHLETIC
GREYSTONE
BS NURSING PRE-CLINICAL
BS NURSING CLINICAL
GRADUATE STUDIES
TRANSFER
NON-TRAD
VOCATIONAL NURSING
INTERNATIONAL
Please indicate your planned Start Date:
FALL/YEAR 20 ___
SPRING/YEAR 20 ___
SUMMER/YEAR 20___
Are you planning to live on campus?
Yes
No
Don’t Know
If an athlete, indicate which sport(s): _____________________________
PLEASE PRINT CLEARLY:
TODAYS DATE:______________________________
__________________________________________________________________________________________________
LAST NAME
FIRST NAME
MIDDLE NAME
NICKNAME
DATE OF BIRTH
AGE
___________________________________________________________________________________________________________________________
PO BOX OR STREET
CITY
STATE
ZIP CODE
___________________________________________________________________________________________________________________________
HOME PHONE
CELL PHONE
PREFERRED EMAIL ADDRESS
ALTERNATE EMAIL ADDRESS
EMERGENCY CONTACT (relative/friend):_____________________________________________________
RELATIONSHIP___________________
___________________________________________________________________________________________________________________________
ADDRESS OF CONTACT:
PO BOX OR STREET
CITY
STATE
ZIP CODE
____________________________________________________________________________________________________________________________
_______
EMERGENCY CONTACT’S HOME PHONE
WORK PHONE
CELL PHONE
E-MAIL ADDRESS
*
IMMUNIZATION REQUIREMENTS AND RECOMMENDATIONS
FOR ALL SCHREINER UNIVERSITY STUDENTS:
PLEASE ATTACH A COPY OF THE FOLLOWING IMMUNIZATION RECORDS. (RETAIN ORIGINAL IMMUNIZATION DOCUMENTS FOR YOUR FILES.)
1.
MENINGITIS: *ALL ENTERING STUDENTS 29 years or younger on first day of classes, are required to have a meningitis vaccination within five
years and 10 days prior to start of classes (
*See Requirement details on Page 3)
2.
TETANUS/DIPHTHERIA (
T
): Last tetanus booster within past 10 years
TD OR
DAP
3.
POLIO (
): Primary Series completed, including booster vaccine
OPV OR IPV
MEASLES, MUMPS, RUBELLA VACCINE (
4.
): Two doses or Certificate of Immunity documented by a healthcare office
MMR
5.
VARICELLA: Two doses or Certificate of Immunity documented by a healthcare office
6.
HEPATITIS A SERIES: Two doses or Certificate of Immunity documented by a healthcare office
7.
HEPATITIS B SERIES: Three doses or Certificate of Immunity documented by a healthcare office
8.
QUADRIVALENT HUMAN PAPILLOMAVIRUS VACCINE (HPV): Strongly recommended for all students 11 - 26 years of age
9.
INTERNATIONAL STUDENTS ARE REQUIRED TO HAVE A TB TEST OR CHEST X-RAY WITHIN ONE YEAR OF START OF CLASSES
*
EXEMPTIONS
TEXAS STATE LAW ALLOWS
(A)
PHYSICIANS TO WRITE A STATEMENT INDICATING THE VACCINE REQUIRED WOULD BE MEDICALLY HARMFUL OR INJURIOUS TO THE HEALTH AND WELL
BEING OF THE STUDENT,
AND
(B)
PARENTS/GUARDIANS TO CHOOSE AN EXEMPTION FROM IMMUNIZATION FOR REASONS OF CONSCIENCE, INCLUDING A RELIGIOUS BELIEF. THE LAW
DOES NOT ALLOW THE PARENTS/GUARDIANS TO ELECT AN EXMPTIONS SIMPLY BECAUSE OF INCONVENIENCE (FOR EXAMPLE A RECORD IS LOST OR
INCOMPLETE AND IT WOULD BE TOO MUCH TROUBLE TO GO TO A PHYSICIAN OR CLINIC TO CORRECT THE PROBLEM.
PLEASE CONTACT HEALTH & WELLNESS AT LEAST 30 DAYS BEFORE START OF CLASSES IF REQUESTING AN EXEMPTION.
The required exemption form from the Texas Department of State Health Services must be used and can be requested at this website :
https://webds.dshs.state.tx.us/immco/affidavit.shtm
.
Please allow several weeks for delivery.
Schreiner University Health History Form 2012-2013 (1/27/2012) FL
Page 1
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