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Student Health Services MEDICAL FORM 421 South Campus Ave. ' X; A6 }2 y+ Q" r
Miami University International Undergraduate Oxford, Ohio, 45056
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The information on this form is confidential and will not be released outside the Health Service without authorization from the student. 5 n/ R: a8 }0 b4 t; Z
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NAME________________________________________________________________________________________________________ 7 a/ T+ M2 U: T2 R8 e5 A
Last First Middle
- A9 |3 P+ B4 s. e1 vBirth date________/________/________ ___________________________________________________ Male______ Female______ - P" y6 z9 l$ }, m7 D$ I) G+ X/ H
State/Country of birth - Y5 |6 l; Z# k
Permanent Address ___________________________________________________________________ Phone (_____)______________ $ A; Z7 Z7 r5 S/ U
Street Address City State Zip
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Parent, Guardian, or Emergency Contact:
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__________________________________________________________________________(_____)____________ (_____)___________
$ S0 H# J! i6 a. s& r4 O9 Q, RName Address-if different than above Home Phone Work Phone
8 @2 U( z5 F, S$ L7 v- }! u__________________________________________________________________________(_____)____________ (_____)___________
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1 N% f" O5 |' z% B7 sName Address-if different than above Home Phone Work Phone # q1 A, }* m% W$ [* k' y6 x6 I; @. x
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Personal Physician ____________________________________________________________________________ (_____)____________
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# m9 d5 q# Z& E, R- I$ z/ YPlease provide dates of immunizations or copy of immunization record 1 Z# O' M: I& _/ c( m9 _
REQUIRED for University attendance if under 30 years of age
" ]# }0 N: h& h0 H8 C, U1 xMeasles via one of the following: * X9 V3 t7 O: u
a) MMR - 2 doses after one year of age 1 2
, g6 m6 O9 `' H; z# s9 |" T j( xb) MMR - within 5 years 1
$ D) E( G7 Z. oc) Measles vaccination - 2 doses after one year of age 1 2
7 U4 T5 h5 i- Rd) Measles blood titer - test results MUST be attached 1 _: `0 R+ |* e) O, [7 d
Recommended but not required for University attendance 6 u& E) Q+ h/ b0 M- p
DPT (Diphtheria-Pertussis-Tetanus, ie baby shots) 1 2 3 4 & g Z5 t1 A$ I7 k! O
Td (Tetanus-Diphtheria) - within last 5 years 1 2
- G% k9 n( o' RHepatitis B - series of 3 shots 1 2 3 0 ~& M9 v E9 r+ y! X4 b5 N( _
Varicella (Chicken Pox) - if you have not had the disease 1 2 Date of Disease:
$ r& ~, P, f4 b: F# h9 gMenomune (meningococcal meningitis vaccine) 1 ' E) j, ]5 i. ~" I3 Z0 k0 _" D
Mumps - if not part of MMR 1 : `7 T* u j( D8 k- @
Rubella - if not part of MMR 1
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" J) z0 U! i4 P" n1 s, iFor questions 1-7 if your answer is yes, please provide additional information on NEXT page of form. Y N / B( n& z8 \* ?4 d- u
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1 Are you allergic to any medications? " B/ P, v3 g+ x) l" n& m8 Y; f
2 Are you allergic to anything else? (bees, pollen, mold, cats, latex, etc.) U* e2 j$ t$ r e* @
3 Do you have any chronic health problem or physical condition that requires periodic medical attention?
9 p7 u( h9 ^6 n6 ]( G' B( Q1 I4 Do you take any medication, either continuously or intermittently? 0 L) e7 o% Y* H% ^
5 Have you had any surgeries or hospitalizations? List date and diagnosis on back of form.
$ \( R+ L* R5 q, `3 _6 Do other members of your family have any current medical problems? Please list on back of form.
% J) U: `: a) ^8 `7 Is there any other information you feel would enhance the Health Service's ability to provide you with
+ V$ O0 w$ Q, S# q" g6 Zgood health care? In particular, copies of any physician or hospital records that might be useful. 9 c0 e8 E2 B" F c% C0 \4 I. u
& g; Q. u; W* ?1 P* H- xThe above is true to the best of my knowledge. PERMISSION is hereby granted to the Student Health Service staff to ; E- f: U7 G% G b5 L( e9 H
provide treatment/preventive care of this student. PERMISSION is also granted to the Student Health Service to refer
& c Q0 F- U9 ]; u! E" m* lthis student to another duly licensed physician or surgeon when indicated.
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Signature of Student Date Signature of Parent 9 G" M, [# f; F$ Q& x% o
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If student is a minor and under 18 years of age, he/she cannot be treated at the Health Service without parental ! O7 K7 K3 i# `
consent as indicated by the above signature. Under an exception to Ohio law, minors can be seen for contraception # _: ?6 i" F, w, r
and sexually transmitted disease treatment without parental consent. If the student is under 18 but not legally a 5 x; y8 k1 J/ C
minor, proof of emancipated minor status should be attached.
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$ l2 L# s" M2 zComplete next page of form as indicated
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Return to: Office of Admission 4 L# k0 B5 a$ D* J$ a! P
8 v1 v$ @$ q& G6 ^0 iMiami University
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" _* z+ ]" W- u5 ?5 q1 }/ gOxford, Ohio, 45056 mf:11-03 ) {- H, g9 K& d5 L
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Please use this side for additional information as requested on the first page of the form: E1 F; _! ^) {3 u* w4 p% c3 C8 p: Z
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Allergic to the following medications: __________________________________________________
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Other allergies: ____________________________________________________________________
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Chronic Health Problems / Physical Conditions that require periodic medical attention: ___________
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! R. E% j" v. q: `7 w( \Continuous Medications and Dosing: ___________________________________________________ & d1 G+ M9 u4 u$ m
Intermittent Medications and Dosing: ___________________________________________________ 7 v% F7 A$ R: ?4 ^9 ]
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Surgeries and Hospitalizations: ________________________________________________________ : i1 }+ g+ m/ g7 Z6 h7 [; }
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Family Medical Problems:
% X+ k# F' ~0 [% R+ u4 M1 WFather:___________________________________________________________________________
# F/ t1 H; ?$ ?% f, c2 qMother:___________________________________________________________________________
7 [6 X% r, ^+ p+ I$ E# p; A4 F; c" pSiblings:__________________________________________________________________________ 9 ]1 V b* o" b! |/ M) j
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Other information: __________________________________________________________________
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