College of Health Professions Required Immunizations, Page 1
Retu rn to: Pacific University, Stu d ent H ealth Services, 2043 College Way, Forest Grove, OR 97116
Fax: 503-352-3105
Phone: 503-352-2269
Please indicate ( ) your program:
Au d iology
H ealthcare Ad m inistration
Pharm acy
Professional Psychology
Dental H ealth Science
Occu p ational Therap y & Re-entry
Physician Assistant
Sp eech Langu age Pathology
Op tom etry
Physical Therap y
IMPORTAN T (PLEASE READ CAREFULLY)
Your program REQUIRES the follow ing immunizations and titers before entering a health profession program, and all required
immunizations and titers must be updated as necessary in order to continue enrollment in a health profession program at Pacific
University. It is the student’s responsibility to timely complete this form and provide copies of proof of vaccinations and titer lab
results. Failure to comply w ith this University policy can affect your admission, enrollment, or ability to continue in a health
professions program at Pacific University.
 If you have questions regarding immunization requirements, please contact your program.
 Immunization record information only w ill be shared w ith your program. Information on your health history is confidential
and protected.
 Your program is responsible for verifying your compliance of immunization requirements.
 Retain original documentation of immunization information and keep these readily available to you—you w ill need these
throughout your program for clinic rotations.
__________________________________
N ame—please print (last, first, middle initial)
Birth date (mo/day/yr)
Signature
Required—Please attach this form to your immunization documentation
Acceptable documentation includes childhood immunization records, immunization records/print-outs from a
provider, and/or lab reports.
Health History Form (com p lete p age 2)
Hepatitis B
o Three d ocu m ented vaccines (Titer w ill su ffice if im m u nization d ocu m entation is not available).
o H ep atitis B Su rface Antibod y titer show ing im m u nity (Mu st have even if you have 3 vaccines)
MMR (Measles, Mu m p s, Ru bella)
o Tw o d ocu m ented vaccines or titer for each show ing im m u nity
Tdap Vaccine (Tetanu s, Dip theria, Acellu lar Pertu ssis). N ote: the tetanu s/ d ip htheria vaccine is u naccep table w ithou t
p ertu ssis
o One d ocu m ented vaccine in the last 10 years
Varicella Vaccine (Chickenp ox)—d ocu m entation of the d isease is not accep table
o Tw o d ocu m ented vaccines or titer show ing im m u nity
Tuberculosis Screening
o N egative Tu bercu losis skin test (PPD) w ithin last 6 m onths. Stu d ents w ith a p ositive PPD m u st obtain
d ocu m entation of a norm al
Chest X-ray, a negative Tsp ot or Qu antiFeron-TB test (QFT).
Required for D ental Health Program and any student w ho participates in international travel. Pacific
strongly recommends Hepatitis A vaccine for all health profession students.
Hepatitis A
o Tw o d ocum ented vaccines.
o I am not in the D ental Health Science Program and w ill not participate in international study programs and therefore I
decline the Hepatitis A vaccine at this tim e. I und erstand that I m ay be exposed to H epatitis A virus d urin g m y program ,
and d espite this risk, I d ecline the H epatitis A vaccination at this tim e. I und erstand that by d eclining this vaccine, I co ntinue
to be at risk of acquiring H epatitis A and that by d eclining this vaccine, I m ay also place patients and cow orkers at risk. In the
event of a H epatitis outbreak, I und erstand I m ay be exclud ed from the university or clinical training placem ent und er the
d irection of the local health officer or the Stud ent H ealth Center Director. In ad d ition, I und erstand that th e H epatitis A
Vaccine series m ay be required by the University or m y program in the future as a cond ition of continued participation in the
program . Should this becom e a requirem ent, this d eclination w ill not be operative. I agree to d efend , ind em nify, a nd release
the university from any and all claim s resulting from m y failure to receive the H epatitis A vaccine.
Student Signature for D eclination of Hepatitis A vaccine:
Date:
2013-14
College of Health Profession Required Immunization Form, Page 2
Return to: Pacific University, Stud ent H ealth Services, 2043 College Way, Forest Grove, OR 97116
Fax: 503-352-3105
Phone: 503-352-2269
Please indicate (
) your program:
Au d iology
Dental H ealth Science
H ealthcare Ad m inistration
Professional Psychology
Occu p ational Therap y
Op tom etry
Pharm acy
Physician Assistant
Physical Therap y
Sp eech-Langu age Pathology
Have you previously attended Pacific University? N o___ Yes____ Last name if different: __________________
Confidential Health History Information: Health history information is protected and confidential and is not
part of your University or Program educational record.
N am e _______________________________________________________________________ DOB:
(Print clearly) Last
First
Mid d le
_________________________________________________________________________________________________________
Perm anent Ad d ress
City
Phone #
________________
State
Male/ Fem ale (circle one)
Zip
Marital Statu s_______ # of Child ren_____
Medications: List any m ed icines you take regu larly, inclu d ing over the cou nter m ed ications/ su p p lem ents ___________
_______________________________________________________________________________________
Allergies: Are you allergic to any m ed icines or latex?
Yes
N o If yes, p lease list and exp lain typ e of reaction:
__________________________________________________________________________________________________________
Ongoing m ed ical or psychiatric/ em otional cond itions: _____________________________________
_______________________________________________________________________________________
N ame of Private Provider/Specialist:___________________________________________Phone:______________________
Personal Medical History: Please check
Allergies (food , d rugs, other) circle
Card iovascular/ heart d isease
Blood clots/ phlebitis
H igh BP/ cholesterol
Diabetes: Type I Type II (circle)
Anem ia or other blood d isord er
Sexually transm itted d isease
Asthm a/ hay fever
Pneum onia
any cu rrent or p ast m ed ical p roblem s listed below .
Depression/ Anxiety
Eating Disord ers
Suicid e attem pt
Meningitis
Concussion/ head injury
Mononucleosis
H epatitis
Thyroid d isord er/ problem s
Kid ney d isease
Tu berculosis
Seizure d isord er
Dizziness/ fainting
Migraine H ead aches
Arthritis
Ulcer
Skin problem s
Chicken pox
Other
H ospitalizations/ Surgeries (Date & Description):_________________________________________________________________________
Personal Habits
Do you use tobacco?
Do you d rink alcohol?
Yes
No
Yes
No
H ave you ever used street d rugs?
Sm oke
Chew
If yes, how m uch?_____________________________________________
If so, how m uch? ________________________________________________________________
Yes
No
If yes, w hat type and how m uch?_________________________________________
Family Medical History
Please check
Yes
the follow ing if there is a history in you r im m ed iate blood relatives, e.g. p arents, siblings or grand p arents.
No
Relationship
Cancer--Type of:
_____________________
Card iac/ H eart Disease
H igh Cholesterol
H igh Blood Pressure
H ead ache
Stroke
Diabetes
Student Signature________________________________
Yes
No
Relationship
Genetic/ Bleed ing Disord er
Seizure Disord er
Asthm a
Depression/ Anxiety/ Suicid e
Other Mental H ealth Problem s
Alcoholism / d rug abuse
Other
D ate _____________________
2013-14