New Student Medical History And Physical Examination Form
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TUDENT
EDICAL
ISTORY AND
HYSICAL
XAMINATION
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Lawrence University Health Services • 711 E. Boldt Way • Appleton, WI 54911‐0599 • Phone: 920‐832‐6574 • Fax: 920‐832‐7488
Wisconsin law states that you must have this form completed with an accurate immunization history
BEFORE you will be allowed to register for classes during Welcome Week web registration.
First name: ______________________
MI: ____
Last name: ______________________
LU ID: _______________
Class: Fr So Jr Sr
Preferred pronoun: _______
Date of birth: ____/____/______ Age: ___ Gender identity: ___________
Home address: _________________________
City: _________________________
State: _____
Zip: ___________
Home phone: __________________
Cell phone: ___________________
Date form completed: ____/____/______
INSTRUCTIONS:
1. Complete Part I (sections A‐D) before physical exam and then take it with you to your physical exam.
2. Part II MUST be filled out by a healthcare provider.
3. Make sure all forms are signed by you (or parent/guardian if under 18) AND by healthcare provider where indicated.
Check here if uninsured:
□
4. Please attach a copy of your insurance card(s) FRONT AND BACK.
5. This form must be filed with University Health Services by August 1.
6. If you are participating in Lawrence University Varsity Athletics, please indicate your sport here: __________________________
P
I ‐‐‐‐ M
H
ART
EDICAL
ISTORY
A. Immunizations‐date of MOST RECENT immunization or active disease.*
*Please attach a copy of immunication record provided by Health Care Provider.
Measles, Mumps, Rubella ‐ TWO DOSES REQUIRED to be able to reside in University housing.
Tetanus immunization within the past ten years is recommended.
REQUIRED – dates must be included (you cannot register for classes without the state required immunizations)
Chicken pox (if you have not had the disease) and meningitis vaccinations are strongly recommended.
Chicken pox (if you have not had the disease) and meningitis
Last Dose:
1
Tetanus, Diphtheria, Pertussis (Tdap)
/
/
vaccinations are strongly recommended.
Last Dose:
2
Polio
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/
Dose 1:
3
Measles
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/
Dose 2:
4
Mumps
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/
Dose 1:
Dose 2:
5
Rubella
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/
/
/
Dose 1:
Dose 2:
Hepatitis B or blood panel results:
6
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/
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/
Dose 1:
Dose 2:
Dose 3:
(This series may be started at home and completed at Lawrence University)
OPTIONAL
1
BCG
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/
Dose 1:
(if not born in USA)
2
Chicken Pox
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/
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/
□
Dose 1:
Dose 2:
(check box if you had the disease:
)
3
Meningitis
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/
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/
Dose 1:
Dose 2:
4
Human Papillomavirus (HPV)
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/
/
/
/
/
Dose 1:
Dose 2:
Dose 3:
5
Other (Typhoid, Hepatitis A, etc)
B. Medications ‐ ‐ ‐ ‐ Please list current medications and supplements, prescription and over the counter.
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4.
2.
5.
3.
6.
C. Allergies ‐ Please indicate which allergies you have and explain reactions below.
Aspirin / Anti‐Inflammatories □Yes □No
Reaction:
Codeine
□Yes □No
Reaction:
Hay Fever / Seasonal
□Yes □No
Reaction:
Insect Stings / Bites
□Yes □No
Reaction:
Latex
□Yes □No
Reaction:
Penicillin
□Yes □No
Reaction:
Sulfa
□Yes □No
Reaction:
Any Foods
□Yes □No
Reaction:
Other:
□Yes □No
Reaction:
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