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. :
Current Height :
Email :
Weight :
Marital Status : Single
Married
FAMILY HISTORY
Please provide information about your father, mother and sibling(s) only.
Disease / Condition
Family Member(s)
Disease Condition
Arthritis
High Cholesterol
Asthma or Allergies
Migraines
Cancer (specify)
Thyroid problems
Depression / Anxiety
Tuberculosis
Diabetes
Other
Heart Disease
If deceased, age and cause of
death
High Blood Pressure
Family Member(s)
PERSONAL MEDICAL HISTORY
Please provide information about yourself. Please answer all questions
Any drug allergies?
None
Yes
Allergies to materials, foods, other?
If yes, please list:
Yes
If yes, please list:
List any medications, vitamins or supplements that you routinely take:
None
List any surgeries or hospitalizations and indicate the year it occurred.
None
Have you had?
None
Yes No Have you had?
Yes No Have you had?
Asthma / Hay fever
Worry or nervousness
Back problems
Chicken pox
Headache/Migraines
Liver disease / Hepatitis
Malaria
Anxiety
Eating disorders
Mononucleosis
Diabetes
Recurrent diarrhea
Tuberculosis
Heart problems
Dizziness, fainting
Gum or tooth trouble
High or low blood pressure
Weakness, paralysis
Cancer: (Type)
Head injury with
unconsciousness
Urinary track infections
Eye trouble / vision
Stomach / Intestinal trouble
Hernia repair
Ear, Nose, Throat trouble
Thyroid problems
Sexually transmitted disease
Seizure disorder
Joint or muscle problems
Recent gain or loss of weight
Trouble sleeping
Physical disability
Learning disability
Question:
Yes No
Yes No
A. Have you received treatment or counseling for a nervous condition, personality or character disorder or emotional
problem? (Give details)
Medical History Report
Page 1 of 3
IMMUNIZATION RECORD
All students must meet the University vaccination requirements as outlined below. You will not be considered a fully matriculated student
until these requirements are met. Failure to comply will result in inability to register for classes and withdrawal from residency privileges in
Campus Housing.
Required Vaccinations for All Entering Full-time Students (Proof of Immunizations must be attached OR physician’s signature)
A. Measles, Mumps, Rubella
I. I have received TWO doses of MMR (Measles, Mumps, Rubella): Trivalent-vaccine
Dose # 1 Date (dd/mm/yy) : / /
Dose # 2 Date (dd/mm/yy) : / /
OR
II. I have received the following separate vaccine doses of Measles, Mumps, Rubella: Monovalent-vaccine
o Measles (Rubeola) Monovalent vaccine
Dose # 1 Date (dd/mm/yy) : / /
Dose # 2 Date (dd/mm/yy) : / /
AND
o
Rubeola (German Measles) Monovalent vaccine
Dose # 1
Date (dd/mm/yy) : / /
o
Mumps Monovalent vaccine
Dose # 1
Date (dd/mm/yy) : / /
AND
Dates unavailable - blood titer enclosed as proof of immunity to measles, mumps and rubella
B. Hepatitis B Vaccine: Three-dose Series (If series not complete, must have evidence that series has been started)
Dose # 1 Date (dd/mm/yy) : / /
Dose # 2 Date (dd/mm/yy) : / /
Dose # 3 Date (dd/mm/yy) : / /
Dates unavailable – blood titer enclosed as proof of immunity
C. Varicella Vaccine (Chicken Pox)
I. Dates of immunization if you have not had chicken pox (Two doses separated by at least 30 days are required)
Dose # 1 Date (dd/mm/yy) : / /
Dose # 2 Date (dd/mm/yy) : / /
OR
II. History of Disease – attached blood titer as evidence of immunity
Dose # 1 Date (dd/mm/yy) : / /
(Varicella Zoster Antibody) Result:
Dates unavailable – blood titer enclosed as proof of immunity
For more information on immunizations, visit: www.immunize.org or www.cdc.gov/ncidodldiseaseinfo
D. Polio (oral): Primary Series
Dose # 1 Date (dd/mm/yy) : / /
Dose # 3 Date (dd/mm/yy) : / /
E.
Date (dd/mm/yy) : / /
Date (dd/mm/yy) : / /
Tetanus – Diphtheria:
I.
II.
F.
Dose # 2
Dose # 4
Complete primary series of tetanus-diphtheria-petusis (DPT) immunization
Tetanus-diphtheria (booster) within the last 10 years
Meningitis Vaccine (Meningococcal) - within past 5 years
G. Tuberculosis Screening
I. PPD Places Date (dd/mm/yy) : / /
PPD Read Date (dd/mm/yy) : / /
Result in mm induration:
Date of last dose (dd/mm/yy) : / /
Date (dd/mm/yy) : / /
Date (dd/mm/yy) : / /
Result:
Result:
Negative
Positive
AND
In case of positively interpreted PPD, a follow up with the healthcare provider is required.
QFT-G
Date (dd/mm/yy) : / /
Result:
Chest X-ray Date (dd/mm/yy) : / /
Result:
OR
II. Previous History of a positive tuberculin skin test
PPD
Date (dd/mm/yy) : / /
* X-ray
Date (dd/mm/yy) : / /
*A normal chest X-ray within 12 months is required, unless history of INH therapy is provided.
Signature and date of Physician or other health care
provider authenticating immunizations.
Medical History Report
Please place physician or health care provider address or
stamp above.
Page 2 of 3
RECOMMENDED VACCINATIONS
H. Hepatitis A
Dose # 1
I.
Date (dd/mm/yy) : / /
Dose # 2
Date (dd/mm/yy) : / /
Human Papillomavirus Vaccine (HPV) – for females only
Dose # 1 Date (dd/mm/yy) : / /
Dose # 2
Date (dd/mm/yy) : / /
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.
How often do you exercise?
Do you use tobacco products?
YES
Cigarettes
NO
Sheesha
NO
YES
cig packs/week
times/week
Average alcohol intake per week?
N/A
None
less than 3x per week
more than 3x per week
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.
__________________________________
Student’s signature
__________________________________
Signature of Parent or Guardian
if student is less than 18 years of age
Date (dd/mm/yy) : / /
Date (dd/mm/yy) : / /
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:
I understand that I am subject to exclusion from Carnegie Mellon’s campus in the event of an outbreak of a disease for which I am not vaccinated.
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. I understand that I am
subject to exclusion from Carnegie Mellon’s campus in the event of an outbreak of any of the above diseases for which I am not vaccinated.
__________________________________
Student’s signature
Medical History Report
__________________________________
Date
Page 3 of 3
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 (tetanus, diphtheria and acellular pertussis) 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.
CMQ and QF Immunization Requirements Information
Page 1 of 1