University of Rochester

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Last modified: Thursday, 04-May-2017 09:37:33 EDT

University Health Service (UHS)

Health History Form Instructions

This set of instructions will help you fill out your Health History and Immunization Report (HHF). Please complete the forms entirely as indicated.

Below are answers to the most commonly asked questions about filling out the Health History Form:

  1. PART ONE – If you are a part-time student you are required to submit a $35 processing fee with this form. (There are no exclusions if you are a University of Rochester employee.)
  2. PART FOUR – Please print your name and then sign and date this section for certification of the information on the form.
  3. PART FIVE – Please carefully read the Instructions for this part on the form.
    1. If you have a serologic test (Titer) for MMR, hepatitis B, and/or varicella, you MUST include a laboratory report with the Health History Form (HHF).
    2. Requirements for The Tuberculin Skin Tests (TST):
      • Non-medical employed students: Two TST tests – The 1st is to be placed less than one year before the start date of the program and the 2nd is to be placed less than 3 months of that start date.
        Example: Start date (9/1/17)
        1st TST (9/1/16 to 8/1/17)
        2nd TST (6/1/17 to 8/30/17)
      • Medical employed students: Same as Non-Medical employed students OR with a consecutive yearly update.
        Example: Start Date (9/1/17)
        1st TST (2016)
        2nd TST (1/1/17 & 9/1/17)
      If you have a past positive TST test, a chest X-ray report MUST be attached to the HHF. The chest x-ray must be taken after the date of the positive TST test.
    3. The TD/Tdap must be within the last 9 years of the start date.
    4. Polio is a mandatory vaccination for all health profession students. Enter the date of your last vaccination on the Health History Form. Either Oral (OPV) or Intramuscular (IPV) forms of vaccine are acceptable.
    5. If you have not received and do not wish to receive hepatitis B or meningococcus vaccine, you MUST sign & date each declination.
  4. PART SIX – You must have one of the following:
    • If a health care practitioner fills out the Health History Form, the practitioner MUST fill out and sign Part Six. – OR -
    • If you have professional documentation that supports the dates you have filled out on the Health History Form, you do not need to enter the information on Part Six. You must send the documentation with your Health History Form.
  5. PART SEVEN – The Physical Examination for Health Profession students MUST be filled out by:
    • A health care practitioner - OR -
    • An accompanying professional health update form must be attached to Part Seven of the Health History Form.

Contact UHS at 585- 275-4955. Include your name, date of birth, UR ID number and preferred mailing address and/or phone number.