Health History Questionnaire Physical
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4Mail or Fax All Forms To:
NJIT – Student Health Services
Estelle & Zoom Fleisher Athletic Center
323 Martin Luther King., Newark, NJ 07102
Website:
Office #: 973-596-3621 – Fax #: 973-596-5517
E-mail:
healthservices@njit.edu
HEALTH HISTORY QUESTIONNAIRE PHYSICAL EXAMINATION
TO THE STUDENT: This information is required that NJIT Student Health Services can provide care based on our particular needs. This form
becomes a part of your student health record. It as well as any other health care information obtained while you are at NJIT, are confidential and will
not be released to anyone without your written permission. These records must be submitted prior to or the day of registration to Health Services. If
your records are not submitted within this time, a HOLD will be placed on your future registration until you provide us with your records.
FULL TIME STUDENT REQUIREMENTS:
PART-TIME STUDENT REQUIREMENTS
Tuberculosis Test within the past 6 months
Same as full-time Student/No Physical Exam
of your registration (test result is needed)
st
Measles (Proof of two doses) after your 1
birthday
Required for ALL Students
MENINIGITIS VACCINE -
st
Mumps (Proof of two doses) after your 1
birthday
st
Rubella (Proof of two doses) after your 1
birthday
AGE EXEMPT REQUIREMENTS
Or a serology test for Mumps, Measles, and Rubella
Those born before 1957 are required to submit blood test (IgG)
(a lab report is needed)
to document immunity to Measles, Mumps, or Rubella.
Physical Exam, by a physician (within the past 6
It is suggested that you also be tested for immunity to
month of your registration)
Varicella (Chickenpox). You do need to submit documentation
Hepatitis B – Proof of 3 doses or lab evidence of immunity
of all other requirements.
Varicella (Chickenpox) (Proof of two doses) or lab
evidence of immunity.
Check The Following: Undergraduate ______ Graduate ______ Full-Time______ Part-Time _______
Name: _______________________________________________________________________Date of Birth:_____/_____/_____
(Last)
(First)
(MI)
NJIT I.D. #________________________Phone #: (
) ______________________ E-mail: _____________________________
Address: ________________________________________________________________________________________________
(Street)
(City)
(State/Country)
(Zip Code)
Campus or Local Address: __________________________________________________________________________________
PERSON TO BE NOTIFIED IN CASE OF EMERGENCY
Name: ___________________________________________________________________________________________________
(Last)
(First)
(MI)
_________________________________________________________________________________________________________
(Street)
(City)
(State)
(Zip Code)
Phone Number: (______)-_______________________________________E-Mail Address: _______________________________
TO PARENTS AND GUARDIAN OF STUDENTS UNDER 18 YEARS OF AGE
I authorize the personnel of NJIT Health Services or authorized personnel of the University to proceed according to good medical practice in
providing medical care of treatment to my child in an emergency or when unable to reach me for authorization.
Parent/Guardian’s Signature: ________________________________________Relationship: ____________Date: ____/____/____
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