Immunization Record

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Personal Information
  First Name   Middle Name    Date of Birth mm/dd/yy    
  Last Name/Family Name    Student ID Number       
  Gender             Viterbo Email         Phone                 
  Home Address 
  Home City    Home State    Home Zip 
 
  Are you able to fill out Immunization Record information below?   
(If you do not have the information at this time, select No and we will contact you later to get this required information.)  
 
IMMUNIZATION RECORD Explanation of Requirements/ Recommendations
 
Have you had COVID-19?   Date of illness:  
COVID-19 Vaccine First Dose - Date:
   mm/dd/yy   		Second Dose - Date:
   mm/dd/yy   		Booster - Date:
   mm/dd/yy  
Booster Brand:
List Brand of Other Booster: 		Primary Brand of COVID-19 Vaccine if known:
List Primary Brand of Other COVID-19 Vaccine:
MMR (Measles, Mumps and Rubella First Dose - Date:
   mm/dd/yy   		Second Dose - Date:
   mm/dd/yy   		TWO doses required. Indicate month, day and year for all doses after 12 months of age. Please note if separate vaccines given.
Varicella (Chicken Pox) History of disease:

    		First Dose - Date:
   mm/dd/yy  

Second Dose - Date:
   mm/dd/yy    		 Vaccination is recommended for all students who have not had the disease in childhood.
Polio Total Number of Doses Received:  Dates: Required to have a record of vaccination against Polio.Need 4 doses and dates listed.
Hepatitis B First Dose - Date:
   mm/dd/yy   		Second Dose - Date:
   mm/dd/yy   		Third Dose - Date:
   mm/dd/yy   		Required for students in clinical health-related studies, but recommended for all students.
Meningococcal First Date Dose Given:
   mm/dd/yy   		Second Date Dose Given:
   mm/dd/yy   		Also recommended for those students who are immunocompromised or for any undergraduate less than 25 who wishes to reduce their risk of disease. ***Highly recommended for all incoming freshman living in dormitories.
TD - Tetanus/ Tdap Most Recent Date:
   mm/dd/yy   		Primary Series DPT or DTAP dates:
 A booster dose is required within the past 10 years. Need 5 doses and dates listed.
Other Immunizations Name: Date: Name:
Date: 		Name:
Date: 		List other immunizations and dates received (ie: BCG, Hepatitis A, HPV, Smallpox, Typhoid, etc.)
  Immunization records may be put into the Wisconsin Immunization Registry?  
The Wisconsin Immunization Registry (WIR) is a computerized internet database that was developed to record and track immunization data.
 
   
TUBERCULOSIS SCREENING
TB Test

** International students are required to provide proof of freedom from Tuberculosis		 TB Skin test (Mantoux)
Date applied:  mm/dd/yy
Date read:   mm/dd/yy
Results:   mm
**If TB test is positive then a chest x-ray is required.		 BCG Vaccine:

Dates:

**International students who have received BCG are required to have a chest x-ray		 Chest X-ray

Date: mm/dd/yy
Results: 		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.
 
 
     Present Health Condition       Do you Smoke?        Do you wear glasses or contacts?
    Are you currently under Medical Care?     Explain:
    Are you currently on any Medications?     List all Medications:  
    Do you have any Allergies
(Medicines, Insects, Environmental or other)?     List all Allergies:
 
 
  History of Illness
     Asthma or Exercise induced Asthma?         Hospitalization or Surgery?   
     Rubella/Mumps/Measles?         Heart Disease?   
     Heart Mumur/High Blood Pressure?         Urinary Tract Infections?   
     Only one of paired organs (i.e.) kidneys, eyes?         History of Anorexia/Bulimia?   
     Skin Problems?         Headaches or Migraines?   
     Chronic Pain?         Racing heartbeat/skipped beats?   
     Muscular problems?         Anemia?   
     Diabetes?         Chest Pain?   
     Back Trouble?         Seizures?   
     Head Injury?         Kidney Disease?   
     Depression/Anxiety?      If you answered yes to any of the
History of Illness, please explain		   
 
   
EMERGENCY INFORMATION
In Case of Emergency Notify   Name:    Relationship:   Phone:  
OR   Name:    Relationship:   Phone:  
Health Care Provider   Name:    Phone:  
Insurance Carrier, Policy No, email/phone# on back of card  
 
Electronic Signature
By signing my name below, I agree that the above information is true and correct to the best of my knowledge.
Student Full Name       
Parent/Guardian Signature (also required if student is under 18)  
Parent Full Name