HEALTH HISTORY AND IMMUNIZATION FORM 1

UNIVERSITY OF VALLEY FORGE - HEALTH CENTER

1401 Charlestown Road, Phoenixville, PA 19460 Phone: 610-917-1465 Fax: 610-917-3915
PLEASE NOTE THIS FORM HAS 4 PAGES

Instructions: All students are required to complete a Health History and Immunization Form. Students who do not complete this
form in its entirety will be ineligible to participate in certain university activities.
Please legibly PRINT the requested information below. he contents of this record are conidential and cannot be
released without your permission.

Name:______________________________________________________________________________________________________
Last First Middle

Home Address: __________________________________________________________________________________________________________

Street City State Zip

Age: _______ Birthday: ______/______/______ Gender: F M Home Phone: (________)______________________

Expected 1st Semester: ______________________ (i.e., Spring 2020, Fall 2020) Cell Phone: (________)______________________

Will you be a commuter, resident living on campus, or online student? _________________________________

Email: ______________________________________________________________________________________________________

Country of Citizenship (if international student): ____________________________________________________________________

EMERGENCY/MISSING PERSON CONTACT INFORMATION

Name _______________________________________________ Relationship __________________________________

Cell/Home Telephone Number (_______)_________________ Work Telephone Number (_______)_______________

Second emergency contact if above is unavailable: Name ____________________ Number (_______)_______________

PHYSICIAN AND INSURANCE INFORMATION

Physician Name __________________________________ Oice Telephone Number (_______)__________________

Health Insurance Company ______________________________ Telephone Number (_______)___________________

Group # ___________________________________ Policy or Contract # ___________________________________

I do not have health insurance. I acknowledge via my initials below that I am responsible for payment
of all my medical bills. I will not hold the university responsible for any medical services I receive while
attending the University of Valley Forge. ________ Student initials required (or guardian if student
is under 18 years of age). If you do have health insurance, write “N/A” (Not Applicable).

PERSONAL HEALTH HISTORY

Do you have a health condition that may require special assistance while you are at UVF? ______ If yes, please specify below:
____________________________________________________________________________________________________________
Would you like to be contacted by the Health Center personnel in regard to the management of this condition? __________________

Are you under the care of a healthcare specialist at present? _________ If yes, please specify: ________________________________

List medications that you take on a daily basis: ______________________________________________________________________

____________________________________________________________________________________________________________
 MANDATORY IMMUNIZATIONS 2
Please enter dates in month, date, year format (mm/dd/yy) in the following chart. Oicial documentation of your immunization
records must be attached to this form, such as copies of medical records, school records and oicial signed immunization cards.
Your immunizations will not be considered valid without oicial copies of immunization records.

Note: UVF does not provide immunizations. You must complete immunizations prior to your arrival on campus.

MENINGITIS Date of Dose Date of Last Booster

(Menactra MCV4 or Menveo)
If student received immunization before their 16th birthday, a booster
dose is needed. Covers meningoccus serogroups A, C, Y, and W-135.

MEASLES, MUMPS,RUBELLA (MMR) Date of First Dose Date of Second Dose

Dose 1 given at 12 months or later.
Dose 2 given at least 28 days after irst dose.

TETANUS-DIPTHERIA Date Series Completed Date of Last Booster

(TD) or (Tdap) or (DTaP) or (Adacel)
Within the last ten years

HIGHLY RECOMMENDED IMMUNIZATIONS

Date of First and Second Dose Date of hird and Forth Dose
HEPATITIS B (3-4 doses)

Date of First Dose Date of Second Dose

HEPATITUS A (2 doses)
Recommended for those students planning on
traveling abroad or working with children.

VARICELLA (2 doses) Date of First and Second Dose Date of Infection (or indicate that you had the disease)
Chicken Pox is a serious communicable disease that can spread
easily. It is strongly recommended that all students be immunized.

Date of First Dose Date of Second Dose

MENINGITIS B (2 doses)
(Bexsero, Trumenda)

INFLUENZA Date of Last Immunization

Commonly known as the “lu,” is an infectious disease caused by an
inluenza virus. An annual immunization is recommended.

Date of First and Second Dose Date of hird Dose

HUMAN PAPILLOMAVIRUS (HPV)
(3 doses)

PNEUMOCOCCAL PCV13 First Dose PPSV23 First Dose

POLYSACCHARIDE VACCINE
(PCV13, Prevnar13, PPSV23)
For people with a weakened immune system or certain long-term
health problems.

Polio Vaccine (IPV) (4 doses) Date of First and Second Dose Date of hird and Fourth Dose
Primary series during childhood; IVP booster only if needed for
travel after the age 18 years.

TUBERCULOSIS (TB) SCREENING QUESTIONNAIRE

Have you had frequent or prolonged visits to one or more foreign countries?
Yes No Name of Country or Countries__________________________________________
Have you been a resident and/or employee of high-risk congregate settings (e.g., correctional facilities, long-term care facilities, and
homeless shelters)?
Yes No
Have you been a volunteer or health-care worker who served clients who are at increased risk for active TB disease?
Yes No
Have you ever been a member of any of the following groups that may have an increased incidence of latent M. tuberculosis infection
or active TB disease – medically undeserved, low-income, or abusing drugs or alcohol?
Yes No
I understand if the answer is YES to any of the above questions, the University of Valley Forge requires that I receive TB testing as soon as
possible. If the answer to all of the above questions is NO, no further testing or further action is required.
* he signiicance of the travel exposure should be discussed with a health care provider and evaluated.
A TB test may be required for Education majors to student teach.
 DO YOU HAVE OR HAVE YOU EVER HAD ANY OF THE FOLLOWING CONDITIONS? 3

Neurological History Yes No Allergies Yes No

Convulsions or seizures Medication allergies (please list)

Dizziness Food allergies (please list)
Other allergies (please list)
Fainting Spells
Frequent or severe headaches Yes No
Digestive
Numbness or tingling in arms or legs Unexplained weight loss or gain
Other Frequent nausea, vomiting, or diarrhea
Frequent constipation
Eyes, Ears Nose and hroat History Yes No Liver disease or jaundice

Persistent pain in eyes Gallbladder disease or gallstones

Peptic ulcer
Persistent watering or itching of eyes
Other
Visual problem afecting ability to see clearly
Frequent earaches Urinary Yes No

Hearing loss Kidney disease or kidney stones

Frequent runny/stufy nose Painful, frequent, or diicult urination
Frequent Sinusitis Nodule in testicle (men only)
Other
Frequent Tonsillitis
Persistent/frequent hoarseness
Menstrual (women only) Yes No
Frequent toothache or sore bleeding gums
Excessive low or clots
Other
Irregular periods
Severe menstrual cramping
Glandular and Blood Yes No
Other
Anemia
Diabetes *
Musculoskeletal and Skin Yes No
Enlarged glands
Acne
hyroid disease
Back pain
Unexplained bruising or bleeding
Other Joint pain
Neck pain

Respiratory Yes No Skin rash

Allergy injections Other
Asthma *
Chronic cough or bronchitis Substance Abuse History Yes No

Frequent or persistent wheezing Alcoholism

Positive TB skin test Drug abuse

Continued on next page

 4
Cardiovascular Yes No Emotional Yes No

Frequent or severe chest pain Depression or excessive sadness

Heart murmur Excessive worry or nervousness
High blood pressure
Suicidal thoughts or attempt
Irregular or very rapid heart heat
Eating disorder (anorexia/bulimia)
Rheumatic fever
Other
Undue shortness of breath
Other

If you answered yes to any of the above questions or have other health problems not covered by this questionnaire, please explain
in detail (use an additional sheet of paper if necessary)

*Diabetic patients or students that use any injectable medications need to obtain proper needle disposal equipment.

If you answered yes to any allergies, please list the allergy, reaction and treatment:

I understand I must send in (mail, email, fax, or attach) an oicial copy of my immunization records from my doctor’s oice
or previous school.
I am aware that my health form will not be complete until I have attached or sent in an oicial copy of my immunization
record from my doctor’s oice or previous school.

CONSENT FOR TREATMENT

Consent is hereby given for treatment in the University of Valley Forge Health Center by duly licensed healthcare person-
nel, or by a Health Care Provider of choice in the community, for routine health care, assessment, diagnosis, treatment, and
if necessary, hospitalization. I agree not to hold the university or anyone acting on its behalf responsible for any injury, or
its treatment thereof, occurring to me in the proper course of any co-curricular or athletic activity. I understand and accept
that there are risks of physical injury involved in co-curricular and athletic activities, which may result in permanent paral-
ysis, mental disability, and death. It is understood that the university will contact the next of kin as soon as possible in the
case of emergency or serious illness.

Signature (student):__________________________________________________Date: ___________________________

Parent or guardian must also sign if the student is under 18 years of age at the time this medical information is submitted.

Signature (parent or guardian):_________________________________________Date:___________________________

Home Phone:________________________________________________ Cell Phone:____________________________

By checking this box and typing my name above, I am electronically signing this document.