Fillable Drake University Medical History Form (Drake University)

Fill Online, Printable, Fillable, Blank Drake University Medical History Form (Drake University) Form

Use Fill to complete blank online DRAKE UNIVERSITY pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Drake University Medical History Form (Drake University)

On average this form takes 56 minutes to complete

The Drake University Medical History Form (Drake University) form is 4 pages long and contains:

  • 4 signatures
  • 122 check-boxes
  • 153 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Drake University

BROWSE DRAKE UNIVERSITY FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
1
Return completed forms to:
Drake University Student Health Center
3116 Carpenter Ave. Des Moines, IA 50311
Phone: 515-271-3731
Fax: 515-271-1855
Email: studenthealthcenter@drake.edu
Drake University Medical History Form
The Drake University Student Health Center requests this confidential information for the purpose of providing patient care. Persons outside the student
health service are not provided this information without the patient’s written consent.
To help us better serve you, please provide a copy of your insurance card.
Please read and complete this document carefully. Failure to complete as instructed could result in future class registration delays. Please send
completed health form/immunization documents directly to the Student Health Center at the above address by the second week after classes start.
Please provide a copy of your insurance card. Send all records at the same time/in the same envelope, FAX or Email.
Student’s Name: Student ID No.:
Last First Middle
Birth Date: Current Age: Sex: Country of Birth:
Home Address:
Street City State ZIP
Home Phone: Cell: Email:
Admission (Circle) Spring Summer Fall Year: Major:
In case of emergency, please contact
1. Contact Name: Relationship:
Cell Phone: Home: Work:
2. Contact Name: Relationship:
Cell Phone: Home: Work:
Medical History—Family
Parental Consent for Minor:
The above named student has my permission to receive services at the Drake Student Health Center. I understand that employees of the Broadlawns
Medical Center staff the Drake Student Health Center in a contractual agreement with Drake University. Permission for my child to receive services shall
remain in effect until my child is 18 years of age. At that time, I understand that my child will no longer need my permission to receive services.
(A parent or guardian can revoke this permission at any time.)
Signature of Parent/Guardian if Student is a Minor: Date:
Age
Occupation
Health Status Deceased
Father
Mother
Siblings
Have any of your relatives
had any of the following?
Yes No Relation Yes No Relation
Arthritis Heart Disease
Asthma, Hay Fever High Blood Pressure
Cancer Mental Health Disorder
Depression Substance Abuse
Diabetes Tuberculosis
Seizures Sickle Cell Anemia
Kidney Disease Other
✔
✔
✔
✔
✔
✔
click to sign
signature
click to edit
2
Have you had or do
you currently have:
Yes No Yes No Yes No Yes No
ADD/ADHD Drug/alcohol abuse Mononucleosis Tuberculosis
Anemia Ear/nose/throat
conditions
Mumps Urinary tract
infections
Anxiety Eating disorder Pneumonia Weakness: paralysis
Asthma Eye conditions Recurrent headaches/
migraines
Weight gain/loss
Back pain Frequent indigestion Seizure disorder Other conditions:
Cancer Gallbladder disease Sexually transmitted
infection
Chest pain/pressure Head injury/
concussion
Shortness of breath
Chicken pox Heart murmur Sickle cell trait
Chronic cough Heart palpitation Sinusitis Female students:
Depression High/low blood
pressure
Sleeping difficulty Irregular periods
Diabetes Jaundice/Hepatitis Stomach/intestinal/
ulcer issues
Pregnancy
Dizziness/fainting Joint injury Thyroid disorder Severe cramps
Yes No Comments
Have you had any illness/injury or surgery which
required hospitalization?
At any time, have any of your activities been restricted due
to illness, injury, etc.? Please explain if yes.
Have you ever experienced any personal or emotional
difficulties that required professional attention or
hospitalization?
If you would like more information about mental health services you may contact
Drake Counseling Center at 515-271-3864.
Please explain any “yes” answers in the Personal Medical History:
Please list any medications you are currently taking:
Please list any allergies and reactions to include medications, food, and environmental:
Medical History—Personal: Please check if you have or have had any of the following:
Student’s Name:
3
Drake University Student Health Immunization History
Obtain copies of your immunization records and attach to this form.
Examples of acceptable documents include:
• Copies of physician office or health department immunization records
• Copies of high school or previous college immunization records
(Please fill in the dates below.)
Student Name: DOB:
To validate this form, have it signed and dated by your health care provider or
authorized immunization official or provide a copy of your immunization record.
Name of Health Care Provider: Signature:
Address: Date (month/day/year): / /
Required immunizations
MMR (Measles, Mumps, Rubella) – 2 DOSES REQUIRED:
Proof of immunity to MMR is a requirement for registration
for classes. This requirement is fulfilled if you meet one of
the following criteria:
• birth date before 1957
• or received two doses of MMR vaccine
(provide both dates)
1: / / 2: / /
**second dose must be at least 28 days after first dose.**
• or received two doses of Measles, Mumps, Rubella
vaccine (provide both dates)
Measles 1: / / 2: / /
Mumps 1: / / 2: / /
Rubella 1: / / 2: / /
• or provide to Student Health Services copies of original
lab reports of MMR titers that verify immunity to these
diseases
Recommended Immunizations (but not required)
Tetanus/Diptheria/Pertussis (TDAP):
Booster (within past 10 years):
Varicella: (birth in the U.S. before 1980, a history of chicken
pox, a positive varicella antibody, or two doses of vaccine
meets requirement)
History of the disease: Yes No
Immunization: Dose 1: Dose 2:
Hepatitis B Series:
Dose 1: Dose 2: Dose 3:
Hepatitis A Series:
Dose 1: Dose 2:
Gardisal (HPV vaccine):
Dose 1: Dose 2: Dose 3:
Strongly Recommended if Living on Campus
Meningitis (Menactra):
Meningitis is an infection of the fluid surrounding the
brain and spinal cord that is caused by a virus or bacteria.
Bacterial meningitis can be severe and cause organ damage
and death. The Meningitis vaccine is recommended for
college freshmen living in residence halls.
To make an informed decision about receiving the vaccine
it is important to read the information provided at the
following websites:
www.cdc.gov/vaccines/hcp/vis/vis-statements/mening.html
or
www.acha.org/topics/meningitis.cfm
Dose 1:
Dose 2: (if Dose 1 was given before age 16)
If you have not received the meningitis vaccine you may
sign a waiver: I am 18 years of age or older or the parent
of a minor child. Drake University has provided me
information explaining the risks of meningococcal disease
and I am aware of the effectiveness and availability of the
vaccine. I do not choose to get the meningococcal vaccine
at this time.
Signature of student or parent/guardian
Date
click to sign
signature
click to edit
click to sign
signature
click to edit
4
Drake University Student Health Center
Tuberculosis Screening Form
Patient Name: Phone:
DOB:
All students are required to complete the below questionnaire.
Students from countries that have a high incidence of TB disease are required to have a TB skin
test upon arrival at Drake University.
Check any that may apply:
Were you born in a high risk Country?
Have you lived in a high risk Country for more than 8 weeks? (See page 5 for list)
Have been diagnosed with a chronic medical condition that may impair your immune system
A health care worker/volunteer in a nursing home, prison, residential institution, or hospital
Have symptoms of active tuberculosis: unexplained weight loss or weakness, coughing up blood, night sweats
Contact with a person known to have active tuberculosis
Productive cough for more than two weeks
(If any of the above apply TB screening is required)
None of the above apply (no TB test required)
Attention international students:
• DO NOT HAVE A TUBERCULOSIS SKIN OR BLOOD TEST DONE PRIOR TO COMING TO THE UNITED
STATES. ALL TB SCREENING MUST BE DONE IN THE UNITED STATES.
• Do not have a BCG vaccination prior to coming to Drake University.
• If you are required to have a chest x-ray, it must be done in the United States within one month of starting at
Drake University.
• If you have had a positive TB skin test OR have been treated for TB infection or disease, bring a copy of your
treatment report written in English.
Date: Time:
PPD 0.1 ml administered on the forearm.
Manufacturer: Lot No.: Expires:
Staff Signature:
The test must be observed 48 to 72 hours after being administered by an approved medical professional
familiar with reading and recording test results.
PPD Read on: Time:
Results are of mm in duration.
Read by:
16-17.7824a
click to sign
signature
click to edit
High Burden TB Country List 2020
(Countries with TB incidence rates of ≥ 20/100,000 population)
Data obtained from 2019 WHO Global Tuberculosis Report and reflects 2018 data
Persons from these countries should be screened for TB and TB infection. Persons from countries not found on this list should
only be tested if symptomatic or if they have risk factors.
Updated 1/5/2020
Afghanistan Dominican Republic Madagascar Sao Tome and Principe
Algeria Ecuador Malawi Senegal
Angola El Salvador Malaysia Serbia
Anguilla Equatorial Guinea Maldives Sierra Leone
Argentina Eritrea Mali Singapore
Armenia Eswatini (formerly Swaziland) Marshall Islands Solomon Islands
Bangladesh Fiji Mexico South Africa
Bangladesh French Polynesia Micronesia (Federated States of) South Sudan
Belarus Gabon
South Korea (Republic of Korea)
Belize Gambia Mongolia Sri Lanka
Benin Georgia Morocco Sudan
Bhutan Ghana Mozambique Suriname
Bolivia Greenland Myanmar (Burma) Tanzania (United Republic)
Bosnia and Herzegovina Guam Namibia Tajikistan
Botswana Guatemala Nauru Thailand
Brazil Guinea Nepal Timor-Leste
Brunei Darussalam Guinea-Bissau Nicaragua Togo
Bulgaria Guyana Niger Tokelau
Burkina Faso Haiti Nigeria Trinidad
Burundi Honduras Niue Tunisia
Cabo Verde India Northern Mariana Islands Turkmenistan
Cambodia Indonesia
North Korea (Democratic People's
Republic )
Tuvalu
Cameroon Iraq Pakistan Uganda
Central African Republic Kazakhstan Palau Ukraine
Chad Kenya Panama Uruguay
China Kiribati Papua New Guinea Uzbekistan
China, Hong Kong SAR Kuwait Paraguay Vanuatu
China, Macao SAR Kyrgyzstan Peru Venezuela
Colombia
Lao People's Democratic
Republic
Philippines Viet Nam
Comoros Latvia Portugal Yemen
Congo Lesotho Qatar Zambia
Cote d'Ivoire Liberia Romania Zimbabwe
Democratic Republic of the
Congo
Libya Russian Federation
Djibouti Lithuania Rwanda
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Drake University Medical History Form (Drake University)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 21 November 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document