Download the Health Form

This checklist is being provided to assist you in completion of your Health Center packet. Before submitting your form, please review the items below for completion:

 ______1.         All required sections of the form are complete.

 ______2.         Proof of immunization/immunity is attached. Acceptable documentation includes: official school record, official health department record, medical record from health care provider’s office. Alternatively, you may have your health care provider complete the immunization section of the Health History Form and sign it. If you are unable to locate immunization records, re-immunization or a blood test, called a titer, to test for immunity is acceptable. Records in a language other than English require translation into English prior to submission to the Health Center.

______3.         I have completed and signed the Tuberculosis questionnaire.

______4.         If I answered “yes” to any questions on the TB questionnaire, I have had my healthcare provider complete and sign the TB Risk Assessment form.

______5.         I have read the enclosed information on the risks of meningococcal disease and Human Papilloma Virus and the availability and effectiveness of vaccination.  I have also read the updated recommendations for Tetanus vaccination.

______6.         I have signed, or if under the age of 18 my parent/guardian has signed the Health History form at the bottom of page 1.

______7.         I am a student ATHLETE. I have completed the Pre-Participation Questionnaire and had a physical exam. The physical exam record is complete and signed by my health care provider.  NOTE: A physical exam is recommended for students who plan to participate in on-campus activities, travel, or study abroad, BUT IS NOT REQUIRED.

Thank You for your attention to these details. We look forward to seeing you in the Fall! If you have any questions, don’t hesitate to contact us at 219-464-5060 or by email at Health.Center@valpo.edu