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Student Medical History form cdr

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Student Medical History form cdr Powered By Docstoc
					NAME__________________________________________ STUDENT ID#_________________________________
IMMUNIZATION POLICY                                                                                                         DATE OF BIRTH:_________/________ /_______
                                                                                                                                                              Month               Day       Year
Stetson University requires documentation of immunization before registration of classes.
RUBEOLA (“Red” or 10-day measles) - All undergraduate students born after December 21, 1956 must provide proof of immunity
to measles.
 A) Documentation of two Rubeola immunizations with live measles virus vaccine, the first being on or after your first birthday; OR
 B) Attach physician s statement on letterhead stating that you had the ten day measles; OR
 C) Provide serological evidence of measles immunity (Blood Titer test)
RUBELLA (German or 3-day measles) - All undergraduate students under to age 40 must provide proof of immunity to Rubella.
 A) Documentation of immunization with live rubella virus vaccine on or after your first birthday; OR
 B) Serological evidence (titer results) of rubella immunity.
PROOF OF IMMUNIZATION MAY BE DOCUMENTED BY:
 A) An original document citing immunization or illness/titer dates bearing Health Care Provider s signature which is legible and
    specifically identified; OR
B) Official stamp of clinic or health center; OR
C) Photocopy of official health record with a health care provider s signature.
EXEMPTIONS of required immunizations policy may be granted in the event of valid medical contraindications or for religious reasons.
  Medical and/or religious affiliation as a basis for exemption must be documented.
UNIVERSITY IMMUNIZATION NON-COMPLIANCE POLICY - Students who do not provide the required Health History form and
documentation of immunization by the time they arrive on campus will be assesses a $50 late fee. Student will be given two weeks to provide SHS with the
required documentation. All students who have not fulfilled this requirement at the end of the two weeks could be subject to eviction from college housing,
registration/account holds and monetary fines.

REQUIRED IMMUNIZATION WITH DOCUMENTATION




                                                                                                                                                                        _____


                                                                                                                                                                                    _____
                 _____ _____
                  First Vaccination Second Vaccination                                                                               Rubella _____
                                                                                                                                             Month Day Year
    Rubeola Month Day
                                  _____
                         _____




                                                                              _____
                                                                 _____




             _____ _____
                      Year Month Day Year                                                                                   (German Measles)
   (Measles)




                                                                                                                                              _____
                                                                                         _____ 1st MMR                                     _____  2nd MMR
                                                                                                                    _____




                                                                                                                                                             _____
                                                                                                     _____




                                                                                                                                                                          _____
          MMR (Measles-Mumps-Rubella) May be given                                       _____
                                                                                         Month    Day  Year                                _____
                                                                                                                                            Month    Day  Year
                  instead of individual immunizations
    _________________                                                                           _________________                                 _________________
                     Physician/Authorized Signature                                                                Date                                       Office Address Stamp
Meningitis and Hepatitis B vaccine or signed waiver are required. If you choose the waiver, you must first read the information about the
diseases provided on the back of this health form.
MENINGITIS VACCINATION                             ______/______/_______        _________________________________
                                                                 Mo.        Day              Year                                   Provider/Authorized signature

    MENINGITIS WAIVER: By checking this waiver box you are stating that you have read the information provided about Meningitis
and understand the potential fatal nature of the disease, the availability of the vaccine and choose not to be vaccinated.
                                             ______/______/_______                           ______________________________
                                                  Mo.      Day             Year                              Student's signature

                                                                                  nd                                           rd
HEPATITIS B VACCINE: Initial ______/_____/______, 2 _____/_____/_______, 3 _____/_____/______ ______________________
                                            Mo.     Day          Year                   Mo.         Day           Year               Mo.      Day          Year       Provider/Authorized signature

    HEPATITIS B WAIVER: By checking this waiver box you are stating that you have read the information provided about Hepatitis B
and understand the potential fatal nature of the disease, the availability of the vaccine and choose not to be vaccinated.
                                      _____/_____/_______ ______________________________
                                              Mo.       Day         Year                              Student's signature

RECOMMENDED IMMUNIZATIONS
TETANUS, DIPHTHERIA, PERTUSSIS(within past 10 years) _____/_____/______ __________________________________________
                                                                                       Mo.          Day          Year                           Provider/Authorized signature
TETANUS, DIPHTHERIA Booster (within past 10 years)                                 _____/_____/______ ___________________________________________
                                                                                       Mo.      Day              Year                           Provider/Authorized signature
POLIO Vaccination (should be completed before age 18)                              _____/_____/______ ___________________________________________
                                                                                       Mo.      Day          Year                               Provider/Authorized signature
HPV Vaccine (Gardasil) : Initial _____/_____/______, 2nd_____/_____/_______, 3rd_____/_____/______ _________________________
                                      Mo.     Day         Year                Mo.        Day              Year                Mo.       Day         Year             Provider/Authorized signature

TB (PPD skin test)(chest x-ray, if positive) NEG_____/POS______, ______/______/______/____________________________________
                                                                                                    Mo.            Day        Year                         Provider/Authorized signature

				
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