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

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/_____