Viterbo University - The University of Opportunity: Hope and Help

Student Health Form

First name   Middle name   Last name  
Social security number     Birth date   Age   Gender  
Address   City   State     Zip   
Phone    Email  
Intercollegiate athlete    If yes, sport  

Immunization Record

MMR - (Measles, Mumps, and Rubella)
TWO doses required. Indicate month, day, and year for all doses after 12 months of age. Not needed if student born before 1957.
First dose date: //  Second dose date: // 
TD - (Tetanus)
A booster dose is required within the past 10 years.
Most recent date:  //  Primary series DPT or DTAP dates:  
Varicella - (Chicken Pox) History of the disease:
Vaccination is recommended for all students who have not had the disease in childhood.
First dose date: //  Second dose date: //  
Required to have a record of vaccination against Polio.
Total number of doses received:   Dates:  
Hapatitis B
Required for students in clinical health-related studies, but recommended for all students. List dose dates:
First:    // 

Second: // 

Third:   //  
Highly recommended for all incoming freshmen living in dormitories. Also recommended for those students who are immunocompromised or for any undergraduate less than 25 who wishes to reduce their risk of disease.
Date dose given: //  
Other immunizations:
List other immunizations and dates received (i.e., BCG, Hepatitis A, Smallpox, Typhoid, etc.)
Name/date:   Name/date:

Name/date:   Name/date:  
Immunization records may be put into the Wisconsin Immunization Registry?
If yes, signature
The Wisconsin Immunization Registry (WIR) is a computerized Internet database application that was developed to record and track immunization dates of Wisconsin's children and adults, providing assistance for keeping everyone on track for their recommended immunizations. The public may access records at if the information has been put into the program.

Tuberculosis Screening

TB Test - International students are required to provide proof of freedom from Tuberculosis.
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.
TB Skin Test - (Mantoux)
Date applied:   Date read:   Results: mm
If TB test is positive then a chest x-ray is required.
BCG Vaccine - International students who have received BCG are required to have a chest x-ray.
Chest X-ray
Date:   Results:  
International students must submit a copy or statement of a TB test or chest X-ray results signed by physician to health services.

Personal Health History

Present health:    Do you smoke?  
Are you presently under medical care?   Explain:

Current medications?   List: 
Allergies (medications, insects, environmental):   List:  

History of Illness

Asthma or exercise-induced asthma 
 Skin problems
 Hospitalizations or surgery
Headaches or migraines
 Tuberculosis exposure
 Dizzy/passed out with exercise
 Chest pain
Heart disease
Cough/sore throat with exercise
Back trouble
Heart murmur/high blood pressure
Racing heartbeat/skipped beats
Only one of paired organ
(i.e., eyes, kidneys, testicles, etc.)
 Heat-related illness
(heat exhaustion or hypothermia)
 Head injury
Knocked unconscious
 Hearing deficiency
 Kidney disease
 Stinger/burner/pinched nerve
History of anorexia/bulimia
Sudden death of immediate family before age 50
 Have you ever sprained, strained, dislocated, fractured, broken, or had repeated swelling or other injuries of any of the following: (check all that apply)
Excessive, unexplained shortness of breath or fatigue with exercise?
Do you use any special equipment such as braces, pads, mouth guards, etc.?
Females only: Regular periods    Age at first period     Menstrual difficulty
Explanation of the above "Yes" responses including dates:

Family history:

Emergency Information

In case of emergency notify:

Name   Relationship   Phone

Name   Relationship   Phone

or health care provider:

Name   Phone

In order to take care of any possible emergency, type your name below to sign the permission statement. If in the opinion of Viterbo University authorities and the attending physician, hospitalization, medical, and/or surgical treatment would be required, I, the undersigned, grant permission for such hospitalization, medical, and/or surgical treatment to be given.

Student signature

Parent/guardian if student is under 18 signature

Note: If student has a medical condition that we need to be aware of for continuing care, email an additional statement by his or her physician to Sue Danielson, coordinator of health services,