IMMUNIZATION FORM
Last Name First Name Date of Birth XID
REQUIRED IMMUNIZATIONS
DATE DATE DATE OF POSITIVE
VACCINE MM/DD/YYYY MM/DD/YYYY LAB/SEROLOGIC
EVIDENCE
minimum 1 month after 1st
MMR 12 Months or Older
dose
(Required if born / / / /
after 1956 or positive
titer)
Measles / / / / / / Copy of Report Attached
Mumps / / / / / / Copy of Report Attached
Rubella / / / / / / Copy of Report Attached
Tdap
/ /
(Required for ages 64
and younger)
Booster required if given
Meningococcal
/ / Vaccine Type: Menactra before age 16 Booster Type: Menactra
(Required if 21 or
Menveo Menveo
younger or waiver)
MenQuadfi / / MenQuadfi
RECOMMENDED IMMUNIZATIONS
VACCINE DATE DATE DATE DATE OF POSITIVE
MM/DD/YYYY MM/DD/YYYY MM/DD/YYYY LAB/SEROLOGIC
EVIDENCE
HEPATITIS A / / / / / / / / Copy of Report Attached
HEPATITIS B / / / / / / / / Copy of Report Attached
HEP A-B / / / / / /
VARICELLA / / / / / / Copy of Report Attached
Series Type: GARDASIL
/ / / / CERVARIX
HPV / /
9-VALENT
Series Type: Trumenba
/ / / / Bexero
Meningococcal B / /
HEALTHCARE PROVIDER SIGNATURE OR STAMP REQUIRED
Name: Signature:
Address: Phone:
, 05/17, 09/22
MEDICAL HISTORY QUESTIONNAIRE
Name (Last, First, M.I.): M□ F□ DOB:
XID:
CU status: □ Student □ Spouse □ Worker’s Comp □ Visitor on Campus □ Exchange Visitor
PERSONAL MEDICAL HISTORY
□ ADHD □ HEADACHES/MIGRAINES □ NEUROLOGICAL DISORDER
PROLONGED IMMUNOSUPPRESSIVE/
□ ALCOHOL/DRUG USE □ HEARING DISABILITIES
□ CORTICOSTEROID TREATMENT
□ ASTHMA □ HEPATITIS B □ CARRIER □ PSYCHOLOGICAL/EMOTIONAL CONCERNS
□ CHICKEN POX □ HEPATITIS C □ SEIZURES
□ CHRONIC FATIGUE □ HIGH BLOOD PRESSURE □ SKIN DISORDERS
□ DIABETES □ HIGH CHOLESTEROL □ SMOKING/TOBACCO USE
□ EATING DISORDERS □ HIV POSITIVE □ THYROID DISORDER
□ EYE DISEASE □ KIDNEY DISEASE □ MALARIA
□ HEAD INJURY WITH UNCONSCIOUSNESS □ MONONUCLEOSIS □ VISION/CORRECTIVE LENSES
Significant Illnesses:
Surgeries: Year:
FAMILY MEDICAL HISTORY
□ ALCOHOL/DRUG PROBLEM □ DIABETES □ HIGH BLOOD PRESSURE
□ ASTHMA/HAY FEVER □ HEART DISEASE/STROKE □ HIGH CHOLESTEROL
□ CANCER □ HEREDITARY DISEASE □ MIGRAINE HEADACHES
□ OTHER SIGNIFICANT ILLNESSES (LIST)
List Any Other Medical Problems:
ALLERGIES (DRUGS AND OTHER SEVERE ADVERSE REACTIONS)
□ NO KNOWN DRUG ALLERGIES □ PENICILLIN □ LATEX
□ ACETAMINOPHEN □ SULFA □ X-RAY CONTRAST
□ ASPIRIN □ FOOD (LIST BELOW) □ OTHER (SPECIFY BELOW)
□ LIDOCAINE/XYLOCAINE □ INSECT/BEE STING
List Any Other Allergies:
Are you currently taking any medications? □ YES □ NO (IF SO, PLEASE LIST BELOW)
Signature of Patient/Guardian Date
Print Name of Patient/Guardian
MED 627: 11/16
