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MAIL HEALTH FORM TO:


University Health Center

Louisiana Tech University

P.O. Box 3023

Ruston, LA 71272-0001



LOUISIANA TECH

U N I V E R S I T Y

RUSTON, LA 71272

This information is strictly for the use of the University

Health Center and will not be released to anyone without your knowledge and consent.


Please type or print. USE INK

MEDICAL HISTORY

Quarter for which you are applying – Fall/Winter/Spring/Summer: ________________


Name (Mr.) (Mrs.) (Ms.)__________________________________________________________________ Soc. Security #______________

Last First Middle Maiden


Date of birth ______/______/______ Age __________ COUNTRY of birth ______________ Sex _____ Height _____ Weight ________
Present Mailing Address ______________________________________________________________________________________________

Number Street City


( )

State Zip Code Telephone Number Major


Next of Kin or person to notify in case of emergency: __________________________________________________ Relationship__________

Address Tel. No. (work) (home)



LOUISIANA TECH UNIVERSITY REQUIRES PROOF OF THE FOLLOWING:

From all students born after December 31, 1956:

Proof of immunity to Measles, Mumps, and Rubella. Acceptable proof includes:


  1. Protective serum titer for Rubella if no documentation of immunization, and

  2. Record of immunization signed by a physician or documentation by physician of Measles and Mumps disease

A Tetanus/Diphtheria combination within the past 10 years.
Rubella vaccine: Date_______________________________________ or Rubella titer and date

Measles vaccine: (FIRST) Date__________________(SECOND) Date_________________________or Measles disease: Date

(Two Measles vaccines must be administered after January 1, 1986, and must have been given on or after the first birthday)

Mumps vaccine: Date______________________________or Mumps disease: Date__________________________________________________

Tetanus/Diphtheria combination: Date________________________________________________________________________________________
Information on immunizations must be authenticated by a physician, Public Health Clinic, or transcript from school record. A photocopy of an official immunization record will also be acceptable.

SIGNATURE AND STAMP OF FACILITY___________________________________________________________________________


ADDRESS STREET/PO BOX CITY STATE ZIP CODE




CERTIFICATE OF MEDICAL EXEMPTION


Medical exemption: The above named student is hereby granted a medical exemption on the basis of certain specific health/physical conditions which are recognized contradictions to the administration of required vaccines.

1. Temporary Exemption Reason ___________________________________________________________________________________________

2. Permanent Exemption Reason ___________________________________________________________________________________________

If permanent exemption due to contraindicated vaccines, are all vaccines contraindicated: Yes ____________________ No________________

If no, designated specific vaccine: ___________________________________________________________________________________________

Signature of Student or Parent _______________________________________________________________________Date ___________________

Physician or Health Provider ________________________________________________________________________Date ___________________

Address _______________________________________________________________________________Telephone No. _____________________



IMMUNIZATION POLICY


Louisiana state law (Act 1047) requires that all persons who are entering Louisiana colleges and universities for the first time and whose date of birth is after 1956, must submit proof of immunization against preventable and/or communicable diseases, including Measles, Mumps, Rubella, and Tetanus-Diphtheria (MMR, Td).
Louisiana Tech University requires all new students born after December 31, 1956 to provide proof of immunization against MMR and Td. Forms for documenting immunization or establishing an exemption to this requirement are available from the Office of Admissions, Louisiana Tech University, Ruston, LA 71272.
Failure to complete and return these forms will result in the inability to complete the registration process.

REQUEST FOR EXEMPTION – PERSONAL DISSENT




I am requesting exemption from compliance with Louisiana state law (Act 1047) for the following personal reasons: ______________________________________________________________


______________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________________

I understand if I claim exemption for personal or medical reasons, that in the event of an outbreak of measles, mumps, or rubella, I may be excluded from attendance of all campus activities, including classes, until the appropriate disease incubation period has expired or until I submit proof of immunization. If I am not 18 years of age, my parent or legal guardian must sign below.
Student’s signature: __________________________________________________________________________ Date: _____________________________________________________________
Parent or Guardian (if required): _______________________________________________________________ Date: _____________________________________________________________

PERSONAL HISTORY

Please answer all questions. Comment on all positive answers in the space below or on an additional sheet.



Are you allergic to:

Yes

No

Have you ever had:

Yes

No




Have you ever had:

Yes

No

Have you ever had:

Yes

No

Penicillin







Appendectomy










Shortness of breath







Head injury with

unconsciousness









Sulfa drugs







Tonsillectomy







High blood pressure







Diabetes






Food








Bone or joint surgery







Heart Murmur or Rheumatic fever







Depression or other

emotional problems









Anesthesia







Tumor, Cancer, Cyst







Lung disease







Recurrent headaches






Have you ever had:



Eye Disease







Peptic ulcer disease







Do you use tobacco?







Hepatitis







Ear, nose, or throat disease







Gall Bladder disease







Alcohol? Other drug?







Measles







Hay fever-asthma







Chronic diarrhea or colitis







Females Only

Mumps







Uticaria (hives)







Kidney disease or blood or sugar in urine







Irregular periods







Malaria









Tuberculosis







Infectious Mononucleosis







Birth Control






ADDITIONAL INFORMATION





Yes

No

Comment on any items checked “Yes” in this Section

A. Are you presently taking any medicine on a regular basis? If so, list.






E. Have you ever been rejected for or discharged from military service or a civilian job because of physical or emotional reasons?












Immunization Completed







Date of last Injection




Has anyone in your family ever had any of the following:







Relationship




Yes

No







Yes

No




Tetanus










Tuberculosis










Diphtheria










Cancer, anemia, blood disease










Polio










Stomach Disease










Pneumonia










Asthma or Hay Fever










Other

























To avoid any delay in registration, please complete and return this form at least four weeks prior to registration. You will not be able to register until this form, including documentation of required immunizations, is complete and on file with the University Health Center.


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