IMMUNIZATION FORM - Clemson University

IMMUNIZATION FORM

Last Name

VACCINE

MMR (Required if born after 1956 or positive titer) Measles

Mumps

Rubella Tdap (Required for ages 64 and younger) Meningococcal (Required if 21 or younger or waiver)

DATE MM/DD/YYYY 12 Months or Older

/ /

/ /

/ / / / Adacel Boostrix / / Menactra Menveo

/ /

First Name

Date of Birth

REQUIRED IMMUNIZATIONS

DATE

MM/DD/YYYY minimum 1 month

after 1st dose / /

DATE OF POSITIVE LAB/SEROLOGIC EVIDENCE

XID

/ / / / / /

/ / / / / /

Copy of Report Attached Copy of Report Attached Copy of Report Attached

Booster required if given before age 16

/ /

Booster Type: Menactra Menveo

I have read and understand the risk of the Meningococcaldiseaseand I am decliningto receive the vaccine.

Declined MeningococcalVaccination Parental/Legal GuardianSignature

Student Signature Required Required for studentsundertheage of 18

VACCINE

HEPATITIS A HEPATITIS B HEP A-B VARICELLA HPV

DATE MM/DD/YYYY

/ / / /

/ / / / / /

RECOMMENDED IMMUNIZATIONS

DATE MM/DD/YYYY

/ / / /

/ /

DATE MM/DD/YYYY

/ / / /

/ /

DATE OF POSITIVE LAB/SEROLOGIC EVIDENCE / /

/ /

/ / / /

/ /

/ /

Series Type: GARDASIL CERVARIX 9-VALENT

Date Date

Copy of Report Attached Copy of Report Attached Copy of Report Attached

Name: Address:

HEALTH CARE PROVIDER SIGNATURE OR STAMP REQUIRED Signature: Phone:

, 05/17

MEDICAL HISTORY QUESTIONNAIRE

Name (Last, First, M.I.):

M

F

DOB:

XID:

CU status:

Student

Spouse

Worker's Comp

Visitor on Campus

Exchange Visitor

ADHD ALCOHOL/DRUG USE ASTHMA CHICKEN POX CHRONIC FATIGUE DIABETES EATING DISORDERS EYE DISEASE HEAD INJURY WITH UNCONSCIOUSNESS

PERSONAL MEDICAL HISTORY

HEADACHES/MIGRAINES HEARING DISABILITIES HEPATITIS B CARRIER

NEUROLOGICAL DISORDER PROLONGED IMMUNOSUPPRESSIVE/

CORTICOSTEROID TREATMENT

PSYCHOLOGICAL/EMOTIONAL CONCERNS

HEPATITIS C HIGH BLOOD PRESSURE

SEIZURES SKIN DISORDERS

HIGH CHOLESTEROL HIV POSITIVE KIDNEY DISEASE MONONUCLEOSIS

SMOKING/TOBACCO USE THYROID DISORDER MALARIA VISION/CORRECTIVE LENSES

Significant Illnesses:

Surgeries:

Year:

ALCOHOL/DRUG PROBLEM ASTHMA/HAY FEVER CANCER OTHER SIGNIFICANT ILLNESSES (LIST)

FAMILY MEDICAL HISTORY DIABETES HEART DISEASE/STROKE HEREDITARY DISEASE

HIGH BLOOD PRESSURE HIGH CHOLESTEROL MIGRAINE HEADACHES

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

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