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Phone: (217) 333-2702

IMMUNIZATION HISTORY
Circle semester of FIRST Enrollment and specify year: Fall (year)_______ Spring (year)_______ Summer (year)_______ ¾Exemption Note: Individuals born before 1957 are exempt from further documentation and need only complete the above section of the
form, as well as the Medical History form. However, completion of the sections below may be useful in providing care. ¾Medical/Religious Exemption: Acceptable medical exemptions are pregnancy, suspected pregnancy, allergies to vaccine,
immunosuppression, or severe illness and must include a physician’s letter. Contact the Dean of Students office for religious exemption. ¾Note to International Students: Tuberculosis screening will be performed at McKinley Health Center upon your arrival to campus.
This section to be completed by a Licensed Provider
IMMUNIZATIONS REQUIRED BY ILLINOIS LAW
Specify dates immunized in the boxes below (A copy of physician/school immunization records is acceptable – please attach) „ MEASLES-MUMPS-RUBELLA – 2 shots against measles, 1 shot against rubella, and 1 shot against mumps (2 recommended)
MMR (strongly recommended) 1
MEASLES (Rubeola)
OR
Positive serum titers are also acceptable proof of immunity against measles, mumps and rubella. „ TETANUS-DIPHTHERIA- PERTUSSIS (DPT, DTP, DT, DTaP, Td, Tdap)

Domestic students: record of at least one tetanus/diphtheria shot within 10 years of enrollment is required.
International students: record of at least three tetanus/diphtheria shots, one within 10 years of enrollment, is required.
OTHER IMMUNIZATIONS – Recommended in certain circumstances but not required
MENINGITIS
Meningococcal meningitis is a potentially fatal, vaccine-preventable illness. We recommend this vaccination for all students, particularly freshmen who live in residence halls, who are at higher risk. This shot is available at the health center for a fee. HEPATITIS A
HEPATITIS B
HUMAN PAPILLOMA VIRUS (females)
VARICELLA
Required Healthcare Provider Verification
I verify to the best of my knowledge that the above immunization information is correct. ¾DOMESTIC STUDENTS: Submit completed Immunization History/Medical History no later than
July 1 for Fall Semester, December 1 for Spring Semester, and April 1 for Summer Semester to:
McKinley Health Center, 1109 South Lincoln Ave., MIS Dept., Urbana, IL 61801
Fax: (217) 244-1758 ƒ Phone: (217) 333-2702
¾INTERNATIONAL STUDENTS: Bring forms with you to campus.
MEDICAL HISTORY – to be completed by student
Please circle those to which you are allergic: Penicillin Sulfa Aspirin Codeine I take allergy shots (specify allergens and frequency) Please list any over-the-counter or prescription drugs (include herbals and birth control pills) that you are taking. Personal Health History
Please check conditions/diseases you have had. If none apply, check this box … Head / Ears / Eyes /
Genital Disorders /
Musculoskeletal
Nose / Throat
Genitourinary
Neurological
Infectious Diseases
Gastrointestinal
… Chickenpox (Varicella)
Cardiovascular
Mental Health
Respiratory
Endocrine
… Asthma
… Diabetes Mellitus
Do you have an illness or condition, not listed above, for which you are now being treated? If yes, specify. List date(s) and reason(s) for any hospitalizations/surgeries. Social Habits: Do you use recreational drugs? …Yes …No Alcohol Family Health History
Has any family member had any of the following? Indicate F=father, M=mother, B=brother, S=sister Person to Notify in Case of Emergency
Name
Signature
¾DOMESTIC STUDENTS: Submit completed Immunization History/Medical History no later than
July 1 for Fall Semester, December 1 for Spring Semester, and April 1 for Summer Semester to:
McKinley Health Center, 1109 South Lincoln Ave., MIS Dept., Urbana, IL 61801
Fax: (217) 244-1758 ƒ Phone: (217) 333-2702
¾INTERNATIONAL STUDENTS: Bring forms with you to campus.

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