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
(Select)
Male
Female
Viterbo Email
Phone
Home Address
Home City
Home State
Home Zip
Are you able to fill out Immunization Record information below?
(Select)
Yes
No
(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?
(Select)
Yes
No
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:
(Select)
Pfizer biontech
Moderna
Other
List Brand of Other Booster:
Primary Brand of COVID-19 Vaccine
if known:
(Select)
Pfizer biontech
Moderna
Other
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:
(Select)
Yes
No
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?
(Select)
Yes
No
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
(Select)
Good
Fair
Poor
Do you Smoke?
(Select)
Yes
No
Do you wear glasses or contacts?
(Select)
Yes
No
Are you currently under Medical Care?
(Select)
Yes
No
Explain:
Are you currently on any Medications?
(Select)
Yes
No
List all Medications:
Do you have any Allergies (Medicines, Insects, Environmental or other)?
(Select)
Yes
No
List all Allergies:
History of Illness
Asthma or Exercise induced Asthma?
(Select)
Yes
No
Hospitalization or Surgery?
(Select)
Yes
No
Rubella/Mumps/Measles?
(Select)
Yes
No
Heart Disease?
(Select)
Yes
No
Heart Mumur/High Blood Pressure?
(Select)
Yes
No
Urinary Tract Infections?
(Select)
Yes
No
Only one of paired organs (i.e.) kidneys, eyes?
(Select)
Yes
No
History of Anorexia/Bulimia?
(Select)
Yes
No
Skin Problems?
(Select)
Yes
No
Headaches or Migraines?
(Select)
Yes
No
Chronic Pain?
(Select)
Yes
No
Racing heartbeat/skipped beats?
(Select)
Yes
No
Muscular problems?
(Select)
Yes
No
Anemia?
(Select)
Yes
No
Diabetes?
(Select)
Yes
No
Chest Pain?
(Select)
Yes
No
Back Trouble?
(Select)
Yes
No
Seizures?
(Select)
Yes
No
Head Injury?
(Select)
Yes
No
Kidney Disease?
(Select)
Yes
No
Depression/Anxiety?
(Select)
Yes
No
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