Article Structure
Completing the Purdue University Medical History Form is a crucial step for students preparing to begin their journey at the university. This form requires careful attention and must be filled out in English. For students born before 1957, the chief requirement is ensuring they have received a Tetanus/diphtheria booster within the last ten years. For those under 18, a medical or religious exemption may be requested, but it needs to be signed by a parent or guardian, as well as the student. Essential information must be provided, including personal details like last name, Purdue ID number, and emergency contact information. The form also outlines vaccination requirements, including the MMR vaccine and others, advising students to provide dates in the standard format of MONTH/DAY/YEAR. Students must be aware of the importance of disclosing any allergies and previous vaccinations for a comprehensive medical history. Additionally, specific guidance is provided for international students regarding the necessity of health insurance. Given the form's complexity and critical importance for campus health and safety, prompt and accurate completion is imperative. Make sure to review and understand all sections before submission to avoid any issues down the line.
Purdue University Medical History Example
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
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
A |
MMR - Measles, Mumps, Rubella |
E |
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Two (2) doses required |
1. _____/_____/_____ |
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after 1st birthday and |
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2. _____/_____/_____ |
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after 1968 |
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Section B required only if |
you did not complete section A |
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B |
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Measles (Rubeola) 2 doses after 1st birthday |
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_____/_____/_____ |
& _____/_____/_____ |
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or titer* _____/_____/_____ |
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Mumps - 1 dose after 1st birthday |
F |
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_____/_____/_____ or titer*_____/_____/_____ |
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Rubella - 1 dose after 1st birthday |
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_____/_____/_____ |
or titer*_____/_____/_____ |
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*- Lab copy required
CTetanus/Diphtheria
Must have had a booster Td within last ten (10) yrs: Tetanus/diphtheria _____/_____/_____ or
Tetanus/diphtheria/Pertussis _____/_____/_____
DAllergies
Please list medication allergies or intolerances
____________________________________
_____________________________________ ______________
Hep B
___/___/___ ___/___/___ ___/___/___
Meningococcal Vaccine ___/___/___
Gardasil
___/___/___ ___/___/___ ___/___/___
Cervarix
___/___/___ ___/___/___ ___/___/___
AUTHORI ZATI ON TO TREAT STUDENTS
UNDER THE AGE OF 18
Please complete the following for students who will be under age 18 at the beginning of the semester:
Pursuant to Indiana Code Paragraph
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Signature of Parent or Legal Guardian |
Date |
____________________________________ |
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Adult Witness |
Date |
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
By signing below, I acknowledge that I have reviewed the above information regarding meningococcal meningitis.
________________________________________ |
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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
____________________________________ |
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Male |
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Female |
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Name of primary policyholder |
Date of birth |
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By signing below, I acknowledge that PUSH** is
_____________________________________ |
_______________ |
___________________________________ |
_______________ |
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
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)
PURDUE UNIVERSITY STUDENT HEALTH CENTER (PUSH**)
601 Stadium Mall Drive
Immunization Offi ce - Room 137 W. Lafayette, Indiana
Form 006 - 5/14
Telephone (765)
Form Characteristics
| Fact Name | Description |
|---|---|
| Form Language | The Purdue University Medical History Form must be completed in English. |
| Td Booster Requirement | Individuals born before 1957 are only required to have a Tetanus/diphtheria (Td) booster within the last ten years. |
| Exemption Requests | Students may request medical or religious exemptions; submissions must be signed by the student, or by a parent/guardian if the student is under 18. |
| Vaccine Recommendations | While vaccines such as MMR and MenACWY are recommended, they are not mandatory. |
| Allergy Disclosure | Students must list any medication allergies or intolerances on the form. |
| Authorization for Minors | For students under 18, a parent or legal guardian must authorize medical treatment as per Indiana Code Paragraph 16-36-1-6. |
| Meningococcal Vaccine Information | Students are informed about the risks of meningococcal disease and the benefits of vaccination. |
| Insurance Requirement for International Students | International students must purchase the university-sponsored health insurance to avoid penalties. |
| Mailing Instructions | Students are encouraged to keep a copy of the form and must return the completed document to the Student Health Center at Purdue University. |
Guidelines on Utilizing Purdue University Medical History
Completing the Purdue University Medical History form is an important step for ensuring proper health documentation before enrolling. The following steps will guide you through the process of filling out the form accurately and completely. Be sure to gather all necessary information before starting.
- Begin by printing the form in English. Use clear and legible handwriting.
- Provide your last name, first name, and middle name in the designated fields.
- Enter your Purdue ID number and date of birth, ensuring you include the month, day, and year in the format (MM/DD/YYYY).
- Select whether you are an international or domestic student by checking the appropriate box.
- List an emergency contact's name and phone number, making sure to include the area code.
- In section E, fill out the vaccine information for MMR (Measles, Mumps, Rubella) if applicable.
- If you did not complete Section A, then fill out Section B with details for your Measles, Mumps, and Rubella vaccinations or titers.
- For Tetanus/Diphtheria information in section C, confirm you received a Td booster within the last ten years, providing the date.
- In section D, list any known allergies or intolerances to medications.
- If you are under the age of 18, complete the authorization section for medical treatment, including signatures from a parent or guardian.
- Read the information regarding Meningococcal disease, and if agreed, sign and date the acknowledgment.
- Provide your insurance information in the designated area and confirm the primary policyholder's name and date of birth.
- If you are an international student, be aware of the requirement to purchase the university-sponsored health insurance and fill out any necessary sections related to that.
- Before submitting, review the form for any missing information or inaccuracies.
- Make a copy of the completed form for your personal records.
- Return the completed form to the Purdue University Student Health Center at the address provided, via mail or fax.
What You Should Know About This Form
What is the purpose of the Purdue University Medical History form?
The Purdue University Medical History form collects essential health information and immunization records from students. It helps the Student Health Center ensure that all students meet health requirements, particularly regarding vaccinations. This is crucial for the well-being of the student body, especially in a campus environment where close contact is common.
Who needs to complete this form?
All students attending Purdue University are required to complete the Medical History form. This includes both international and domestic students. Specific health requirements, such as vaccinations, vary based on the student's background, so it's crucial for everyone to provide accurate information about their health history and immunizations.
What are the vaccination requirements for students born before 1957?
Students born before 1957 are only required to show proof of having received a booster dose of Tetanus/diphtheria (Td) within the last ten years. This is part of the university’s effort to maintain health standards on campus, ensuring that all individuals are protected against preventable diseases.
How should I request a medical or religious exemption?
If a student wishes to request a medical or religious exemption from the vaccination requirements, they must submit their request to the Health Center Director. This request needs to be signed by the student. If the student is under the age of 18, a parent or guardian must also sign, along with the student’s signature. Proper documentation must be provided for the exemption to be considered.
What should international students know about health insurance and vaccinations?
International students at Purdue University are required to purchase the university-sponsored health insurance plan. It is essential to do this before receiving vaccinations like Tdap or MMR and to undergo tuberculosis testing. Failure to secure the required insurance may lead to late fees and holds on class registration. Additionally, tuberculosis testing is mandatory after arriving in the United States, and it can be done either at the Student Health Center or with a local physician.
Common mistakes
Filling out the Purdue University Medical History form can be a straightforward task, yet many students make common mistakes that can lead to complications. One prevalent error is failing to print the information clearly. The form explicitly requires that entries be made in English and in a legible manner. When handwriting is difficult to read, it can delay processing and potentially result in miscommunication regarding a student’s health history.
Another common mistake is not including the proper dates for vaccinations. The form clearly states that responses must follow the MONTH / DAY / YEAR format. Ignoring this guideline can create confusion. For example, writing "01/04/2022" could be interpreted as either January 4 or April 1, potentially affecting the student’s immunization records.
Students might also overlook the requirement to provide documentation for certain vaccinations. The form mentions that a lab copy is needed for titers, such as those for measles, mumps, and rubella. Without this documentation, the vaccinations might not be accepted, complicating the student's enrollment process. Therefore, ensuring that all necessary paperwork accompanies the form is crucial.
Additionally, some students neglect to fill out all sections of the form. For instance, Section B is required for those who did not complete Section A. Failing to provide information in these areas can lead to incomplete records and may delay healthcare services on campus.
Missing the emergency contact information is another serious error. Students might skip this section, thinking it is optional. However, having an emergency contact is essential for situations requiring immediate medical attention. Leaving this information out could hinder timely communication with family members in case of an emergency.
Misunderstanding the requirements for the Tetanus/diphtheria booster is also a frequent oversight. Students born prior to 1957 only need to provide proof of having received a booster within the last ten years. Ignoring this detail or incorrectly assuming the requirement applies to everyone can lead to unnecessary complications.
Moreover, international students sometimes make the mistake of not purchasing the required health insurance in advance. Failure to do so can result in late fees and registration holds, adversely impacting their academic journey. Familiarizing themselves with these prerequisites before submitting the form can save them from such pitfalls.
Lastly, some students may not keep a copy of their submitted form for personal records. Keeping a personal copy can be beneficial for future reference. It allows students to verify what information was submitted and can be helpful in disputes or questions regarding their medical history or insurance coverage.
Documents used along the form
Alongside the Purdue University Medical History form, there are several other important documents and forms that students may need to complete. These forms help ensure that the Student Health Center can provide appropriate care tailored to each student's needs. Below is a list of these supporting forms.
- Immunization Records: This document lists all vaccinations that a student has received, including dates and types of vaccines. It is crucial for fulfilling any immunization requirements set by the university.
- Insurance Information Form: This form collects details about the student's health insurance policy, including the name of the policyholder and the insurance provider. It is essential for processing any medical billing through the university's health services.
- Authorization to Treat Minors: Required for students under 18, this form grants the university health officials permission to provide medical care to the student. It must be signed by a parent or legal guardian.
- TB Test Documentation: International students are required to provide proof of a tuberculosis test conducted after their arrival in the U.S. This document must include the test date and results.
- Medical Exemption Request Form: If a student cannot receive certain vaccinations due to medical reasons, this form must be completed and submitted to request an exemption. It requires detailed medical justification.
- Religious Exemption Request Form: Similar to the medical exemption, this form allows students to provide reasons related to their religious beliefs that prevent them from receiving specific vaccinations.
- Health History Questionnaire: This questionnaire gathers comprehensive health information from students, including past medical conditions, surgeries, and family health history, to guide the health center in delivering personalized care.
Each of these forms plays a vital role in maintaining the health and safety of students on campus. Completing them accurately and submitting them on time is important for ensuring smooth access to medical services and complying with university policies.
Similar forms
The Purdue University Medical History Form is essential for students to provide vital health information. Here are five other documents that are similar in purpose or structure:
- College Admission Health Forms: Like the Purdue Medical History Form, these forms gather detailed health information before students begin their studies. They often include sections on vaccinations, medical conditions, and emergency contacts, similar to the format used at Purdue.
- Vaccination Records: This document records immunizations students have received. It requires dates and types of vaccines, much like the vaccine section in the Purdue form, ensuring that students meet health regulations before attending classes.
- Emergency Contact Forms: These forms request essential contact information for guardians or relatives in case of an emergency. They parallel Purdue’s requirement for emergency contact details, ensuring proper communication when immediate assistance is needed.
- Informed Consent Forms: Much like the authorization to treat section in Purdue’s form, these documents allow medical personnel to provide care. They require signatures from students or their parents, confirming understanding of the treatment process and risks involved.
- Insurance Enrollment Forms: Similar to the insurance information section in the Purdue document, these forms collect necessary details for students' health insurance. They ensure that students are informed of their coverage, similar to how Purdue emphasizes health insurance requirements.
Dos and Don'ts
When filling out the Purdue University Medical History form, it’s essential to approach the process with careful attention to detail. Here is a guide that outlines what you should and shouldn’t do:
- Do print clearly and complete the form in English.
- Do ensure all dates are formatted correctly, including the month, day, and year.
- Don’t leave any required sections blank, especially information about vaccinations and allergies.
- Don’t submit the form without keeping a copy for your personal records.
Misconceptions
The Purdue University Medical History Form is essential for students to provide necessary health information. However, several misconceptions may cause confusion regarding its requirements and implications.
- Misconception 1: All students must receive every vaccine listed on the form.
- Misconception 2: The form can be submitted in any language.
- Misconception 3: A medical exemption process is overly complicated.
- Misconception 4: Meningococcal vaccination is optional.
- Misconception 5: The medical history form has no deadline for submission.
- Misconception 6: International students are exempt from all immunization requirements.
- Misconception 7: Incomplete forms will receive follow-ups from the health center.
In reality, while some vaccines are highly recommended, not all are required. Specific vaccines, such as MMR, have requirements only for certain age groups.
The form must be completed in English to ensure accuracy and compliance with university standards.
Students need only submit their requests for a medical or religious exemption to the Health Center Director. The procedure is straightforward, requiring a signature from the student and, if applicable, a parent or guardian.
All students must read and acknowledge the information regarding meningococcal disease. Although not all students may be required to get vaccinated, the acknowledgment is mandatory.
Students are encouraged to submit the form before the semester begins. Failure to do so may result in delays in health services or academic registration.
This is incorrect. International students are specifically required to obtain a university-sponsored health insurance plan, and they must follow immunization protocols, including tuberculosis testing upon arrival in the U.S.
The health center cannot guarantee contact for incomplete submissions. Students should ensure that their forms are thoroughly completed upon submission.
Key takeaways
When filling out the Purdue University Medical History form, there are several important points to keep in mind. Understanding these takeaways can help ensure that the process goes smoothly and that you meet all necessary requirements.
- Complete and legible answers are essential. The form must be filled out in English, and it is crucial to print all information clearly. This ensures that health officials can read and process the information without issues.
- Vaccination records are important. Students should pay close attention to their vaccine history. Required vaccines, such as the Tetanus/Diphtheria booster within the last ten years, need to be documented accurately with the correct dates. Missing information can delay enrollment processes.
- Submit exemptions properly. If you are seeking a medical or religious exemption for vaccinations, it's essential to follow the proper channels. The request must be directed to the Health Center Director, and signatures from both the student and, if applicable, a parent or guardian are necessary.
- Insurance information matters. Students are encouraged to provide their insurance details fully and accurately. Purdue University currently operates out-of-network for most insurance plans, which can lead to questions regarding costs and coverage if not addressed beforehand.
Maintaining careful attention to these details can help facilitate a smoother experience when submitting the Purdue University Medical History form.
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