Immunization Record

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Personal Information
  First Name   Middle Name    Date of Birth mm/dd/yy    
  Last Name/Family Name    Student ID Number       
  Gender             Viterbo Email         Phone                 
  Permanent Address 
 
IMMUNIZATION RECORD Explanation of Requirements/ Recommendations
MMR (Measles, Mumps and Rubella   First Dose - Date:
   mm/dd/yy  
  Second Dose - Date:
   mm/dd/yy  
TWO doses required. Indicate month, day and year for all doses after 12 months of age. Please note if separate vaccines given.
Varicella (Chicken Pox)   History of disease:

   
First Dose - Date:
   mm/dd/yy  

Second Dose - Date:
   mm/dd/yy    
Vaccination is recommended for all students who have not had the disease in childhood.
Polio   Total Number of Doses Received:    Dates: Required to have a record of vaccination against Polio.Need 4 doses and dates listed.
Hepatitis B First Dose - Date:
   mm/dd/yy  
Second Dose - Date:
   mm/dd/yy  
Third Dose - Date:
   mm/dd/yy  
Required for students in clinical health-related studies, but recommended for all students.
Meningococcal First Date Dose Given:
   mm/dd/yy  
Second Date Dose Given:
   mm/dd/yy  
Also recommended for those students who are immunocompromised or for any undergraduate less than 25 who wishes to reduce their risk of disease. ***Highly recommended for all incoming freshman living in dormitories.
TD - Tetanus/ Tdap   Most Recent Date:
   mm/dd/yy  
  Primary Series DPT or DTAP dates:
A booster dose is required within the past 10 years. Need 5 doses and dates listed.
Other Immunizations Name: Date: Name:
Date:
Name:
Date:
List other immunizations and dates received (ie: BCG, Hepatitis A, HPV, Smallpox, Typhoid, etc.)
  Immunization records may be put into the Wisconsin Immunization Registry?  
The Wisconsin Immunization Registry (WIR) is a computerized internet database that was developed to record and track immunization data.
 
   
TUBERCULOSIS SCREENING
TB Test

** International students are required to provide proof of freedom from Tuberculosis
TB Skin test (Mantoux)
Date applied:  mm/dd/yy
Date read:   mm/dd/yy
Results:   mm
**If TB test is positive then a chest x-ray is required.
BCG Vaccine:

Dates:

**International students who have received BCG are required to have a chest x-ray
Chest X-ray

Date: mm/dd/yy
Results:
Recommended within the past 12 months for all students prior to entering the university.
May be required for students in clinical health-related, educational and human services studies.
 
 
     Present Health Condition       Do you Smoke?        Do you wear glasses or contacts?
    Are you currently under Medical Care?     Explain:
    Are you currently on any Medications?     List all Medications:  
    Do you have any Allergies
(Medicines, Insects, Environmental or other)?     List all Allergies:
 
 
  History of Illness
     Asthma or Exercise induced Asthma?         Hospitalization or Surgery?   
     Rubella/Mumps/Measles?         Heart Disease?   
     Heart Mumur/High Blood Pressure?         Urinary Tract Infections?   
     Only one of paired organs (i.e.) kidneys, eyes?         History of Anorexia/Bulimia?   
     Skin Problems?         Headaches or Migraines?   
     Chronic Pain?         Racing heartbeat/skipped beats?   
     Muscular problems?         Anemia?   
     Diabetes?         Chest Pain?   
     Back Trouble?         Seizures?   
     Head Injury?         Kidney Disease?   
     Depression/Anxiety?      If you answered yes to any of the
History of Illness, please explain
   
 
   
EMERGENCY INFORMATION
In Case of Emergency Notify   Name:    Relationship:   Phone:  
OR   Name:    Relationship:   Phone:  
Health Care Provider   Name:    Phone:  
Insurance Carrier, Policy No, email/phone# on back of card  
 
Electronic Signature
By signing my name below, I agree that the above information is true and correct to the best of my knowledge.
Student Full Name       
Parent/Guardian Signature (also required if student is under 18)  
Parent Full Name