Medical History Report

MEDICAL HISTORY REPORT

Last Name: First Name:

Qatar ID #: Sex: F M DOB (dd/mm/yy): Age:

Mailing Home Address:

City: Country:

Phone No. Home: Mob.: Email:

Current Height: Weight: Marital Status: Single Married

FAMILY HISTORY

Please provide information about your father, mother and sibling(s) only.

PERSONAL MEDICAL HISTORY

Please provide information about yourself. Please answer all questions.

Any drug allergies? None Yes

Allergies to materials, foods, other? None Yes

List any medications, vitamins or supplements that you routinely take: None

List any surgeries or hospitalizations and indicate the year it occurred. None

Question:

A. Have you received treatment or counseling for a nervous condition, personality or character disorder or emotional problem? (Give details) Yes No

IMMUNIZATION RECORD

All students must meet the University vaccination requirements as outlined below.

Required Vaccinations for All Entering Full-time Students

A. Measles, Mumps, Rubella

I. I have received TWO doses of MMR (Trivalent-vaccine)
Dose #1 Date: Dose #2 Date:

OR

II. Separate vaccine doses:

Measles Dose #1: Dose #2:

Rubella Dose #1: Mumps Dose #1:

Dates unavailable - blood titer enclosed as proof of immunity

B. Hepatitis B Vaccine

Dose #1: Dose #2: Dose #3:

C. Varicella Vaccine (Chicken Pox)

Dose #1: Dose #2:

History of Disease / Antibody Result:

D. Polio (oral): Primary Series

Dose #1: Dose #2: Dose #3: Dose #4:

E. Tetanus - Diphtheria

Date of last dose:

Booster within last 10 years:

F. Meningitis Vaccine

Date (within past 5 years):

G. Tuberculosis Screening

PPD Placed Date: Result:

PPD Read Date: Result:

Result in mm induration: Negative Positive

QFT-G Date: Result:

Chest X-ray Date: Result:

Previous positive PPD Date: X-ray Date:

RECOMMENDED VACCINATIONS

H. Hepatitis A

Dose #1: Dose #2:

I. Human Papillomavirus Vaccine (HPV) – for females only

Dose #1: Dose #2:

EMERGENCY CONTACT INFORMATION

Name of contact and relationship:

Mobile No.: Work Phone No.:

PREVENTIVE HEALTH

This information is CONFIDENTIAL and for SHC use only. We will not release without specific consent from you.

Do you use tobacco products?
Cigarettes NO YES
Sheesha NO YES

How often do you exercise? None less than 3x per week more than 3x per week

Average alcohol intake per week? N/A Do you consistently wear a seatbelt? NO YES

FOR ALL STUDENTS

By signature, I verify that the information provided on this form is true and I give permission for such diagnostic, therapeutic, and operative procedures as may deemed necessary for me.

REMARKS OR ADDITIONAL INFORMATION

MEDICAL EXEMPTION

Complete only if applicable. Check only that apply.

I have been advised by my physician that I should not receive vaccination for:

Measles Mumps Rubella Hepatitis B Meningitis

Due to the following medical condition:

Name of physician: Office phone number:

RELIGIOUS EXEMPTION

Complete only if applicable.

I affirm that immunization is in conflict with my religious beliefs. I understand the risks and am choosing not to be vaccinated at this time.

Student's signature: Date:

CARNEGIE MELLON QATAR AND QATAR FOUNDATION IMMUNIZATION REQUIREMENTS

PLEASE READ CAREFULLY.

• HEALTH CARE PROVIDER: a physician licensed to practice medicine in all of its branches (M.D. or D.O.), a Licensed Nurse, or a Public Health Official.

• ENGLISH: All immunization forms and copies of laboratory reports must be submitted in English. Translations of non-English documents must be certified.

REQUIRED VACCINATIONS:

• MEASLES, MUMPS, RUBELLA: A copy of laboratory report(s) in English with evidence of immunity to Measles, Mumps, and Rubella. Students whose laboratory testing does not indicate immunity should receive additional immunizations as appropriate and record these dates.

• HEPATITIS B: Students should submit a copy of a laboratory report(s) in English of a blood test (Hepatitis B surface Antibody) to demonstrate immunity. Students whose laboratory testing does not indicate immunity should receive additional immunizations as appropriate and record these dates.

• VARICELLA: Students who have previously had Varicella infection (chicken pox) should have their immunity verified with a blood titer and submit a copy of laboratory report(s) in English. Students who have not previously been infected or whose laboratory testing does not indicate immunity should complete the two-dose vaccination series. Vaccines should be given at least 30 days apart.

• TETANUS, DIPHTHERIA, PERTUSSIS: All students must show proof of vaccination for Tetanus, Diphtheria and Pertussis within the past ten years. Proof of immunity may be submitted by forwarding a copy of childhood immunization records, or a recent dose of Tdap. For students who currently require vaccination, the Tdap vaccine is needed to satisfy the pertussis requirement.

• TUBERCULOSIS SCREENING: Screening for tuberculosis exposure is a skin test (PPD) performed within the last 12 months. Students with a previous history of a positive tuberculosis skin test must submit a chest X-ray report obtained within 12 months of entry. They should not have skin testing completed.

• POLIO: All students must show proof of vaccination for Polio. Proof of immunity may be submitted by forwarding a copy of childhood immunization records, or a recent dose of the vaccine.

• MENINGOCOCCAL: Students must show proof of vaccination for Meningococcal within the past 5 years. Either Conjugate (preferred) or Polysaccharide.

RECOMMENDED VACCINATIONS:

• HEPATITIS A: A series of 2 shots

• INFLUENZA: Recommended that vaccine be given annually.

• HPV: Series of 3. (For females only)

• PNEUMONCOCCAL POLYSACCHARIDE VACCINE

• TYPHOID: Students must show proof of vaccination for Typhoid or booster within the past 2 years.

MEDICAL CONTRAINDICATIONS:

A written, signed, and dated statement from a physician stating the vaccine that is contraindicated, the nature, and duration of the medical condition that contraindicates the vaccine(s). Submit this statement with application to your university.

RELIGIOUS EXEMPTION:

A written, signed, and dated statement by the student detailing the student’s objection to immunization on religious grounds. Request for religious exemptions will be forwarded for review and only be granted by the Registrar. Submit this statement with application to your university.

The attached immunization form must be:

1. Completed in English by a Health Care Provider and stamped or if completed by non-medical person immunization records must be attached.

2. The immunization form must be returned to your university’s Health and Wellness Counselor.

3. Do not send original immunization booklets/documents – make a copy & complete attached form.