lehigh university immunization record
TRANSCRIPT
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LEHIGH UNIVERSITY IMMUNIZATION RECORD 2021/2022
If the immunization requirements are not met, the student will NOT be permitted to obtain their residence hall key. Please record dates (month/day/year) below -- the Lehigh University Health & Wellness Center
will ONLY accept documentation on this form as proof of immunization status.
NAME Last First Middle
D.O.B. ________/_________/_________Month Day Year
REQUIRED IMMUNIZATIONS 1st DoseDate
2nd Dose Date
3rd DoseDate
BoosterDate
1. Hepatitis B A 3-shot series is required. First of 3 must have beengiven prior to enrollment at Lehigh. A blood test report showingimmunity is acceptable. Please attach report.
2. MMR (Measles/Mumps/Rubella) Two (2) doses after age 12 months,given at least 28 days apart. Blood test reports indicating immunityare acceptable. Please attach report.
3. MENINGITIS (Serogroup A,C,Y, W135) after age 16.Menactra, Menveo or Menomune
4. Meningitis (Serogroup B) Must be started prior to enrollment at Lehigh.
Bexsero 2 dose series completed within 2 months.
Trumenba 2 or 3 dose series completed within 6 months.
5. Polio (OPV or IPV) Basic series of three doses and last booster after age 4.
6. Tdap (Tetanus/Diphtheria/Pertussis) Adacel or Boostrix, within 10 years.
7. Varicella (Chicken Pox) Two doses requiredORHistory of having the disease or blood test report indicating immunity by providing laboratory report is acceptable. History of Disease date
OTHER IMMUNIZATIONS RECEIVED (highly recommended but not required):
Hepatitis AHPV (Human Papillomavirus Vaccine)PneumococcalInfluenza
M D Y
M D Y
M D Y
M D Y
M D Y
M D Y
M D Y
M D Y M D Y
M D Y M D Y M D Y
M D Y M D Y M D Y M D Y
M D Y
M D Y M D Y
M D Y
I certify that to the best of my knowledge the information provided on this form is true and complete.
Date ________________________ Healthcare Provider’s Signature _____________________________________________________
Telephone: (_________) __________________________ Fax: (__________)_____________________________________
OR
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LEHIGH UNIVERSITY PHYSICAL EXAMINATION 2021/2022Physical examination required for ALL incoming students, MUST BE DONE WITHIN SIX (6) MONTHS prior to your first day of class at Lehigh University
NAME _____________________________________________________________ D.O.B. _______/_______/_______Last First Middle Month Day Year
Food Allergies: ( )NO ( )YES:_________________________________________________________________________________________
History of Anaphylaxis: ( )NO ( )YES, what was the trigger? _____________ Does student carry an EpiPen or AuviQ? ( )NO ( )YES MEDICAL and SURGICAL HISTORY, please indicate if student has a history of any of the following.
NORMALNOTEXAMINED
Head, Eyes, Ears, Nose, Throat
Lymph Nodes
Cardiovascular/Pulses
LungsAbdomenGenitourinary
Musculoskeletal
Neurologic
This student has been tested for sickle cell trait: ( ) NO ( ) YES, must provide documentation of test results.
This student is medically cleared for sports participation: ( ) Unlimited ( ) Limited ( ) Not Cleared, provide details: ______________________________
I certify that to the best of my knowledge the information provided on this form is true and complete.
Date: _________________ Physician/Healthcare Provider’s Signature: ___________________________________________________________
Office Address: _____________________________________________
Office Phone: ______________________________________________ OFFICE STAMP
Offfice Fax: ________________________________________________
Examination Date: ________/________/________Month Day Year
Current prescription and nonprescription medication(s) with dosage(s):________________________________________________________
_______________________________________________________________________________________________________________________
Medication Allergies: ( )NO ( )YES: __________________________________________________________________________________
Skin
REQUIRED FOR VARSITY ATHLETIC PARTICIPATION:
General Appearance
ABNORMAL - describe findings
Anemia
Sickle Cell Disease
Sickle Cell trait
Infectious Mononucleosis
Positive PPD or QTB
Active Tuberculosis
Asthma
COVID -19
Inflammatory Bowel Disease
Rheumatoid Arthritis (or JIA)
Lupus (SLE)
Diabetes Mellitus
Thyroid Disorder
Seizure Disorder
Hypertension
Marfan Syndrome
Headache Disorder
Head injury/Concussion
Syncope
Kawasaki Disease
Arrhythmia-WPW, prolonged QT
Eating Disorder
Skin Condition
Celiac Disease
Immunocompromising condition
ADHD
Anxiety
Depression
Bipolar Disorder
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NOYES NO
YES NO
YES NO
YES NO
YES NO
Provide details for any YES answers:_________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ Was the student born without, or are he/she/they missing a kidney, eye, testicle, ovary or any organ? ( )NO ( )YES: _____________________ Prior Surgery? ( )NO ( )YES, provide details:______________________________________________________________________________ Prior Hospitalization? ( )NO ( )YES, provide details:_________________________________________________________________________ PLEASE INCLUDE ANY RECOMMENDATIONS THAT WOULD BE IMPORTANT FOR THE CARE OF THIS STUDENT: ______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________Physical Examination: BP ___________ P _______ HT _______ WT _______ BMI _______ Vision: R 20/_____ L 20/_____