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Health History Form

Penn State requires all students to submit a completed Health History form provided by the University. This form documents immunization against Measles, Mumps and Rubella (German Measles). Two doses of Measles (Rubeola) vaccine, one dose of Mumps and one dose of Rubella are required to assure immunity.

If you have lost your childhood records, it is acceptable for your current health care provider to give you an MMR immunization now and record the date beside "2nd immunization" on the form. If you were born in 1956 or before, you are considered immune to Measles, Mumps and Rubella and do not need to receive the vaccine. If this is the case, please complete the demographic and medical history part of the form and mail it to the address on the top of the form.

Exemptions to this University requirement based on religious beliefs or medical reasons will be evaluated on an individual basis. Requests for exemption should be sent to Dr. Margaret Spear, Director of University Health Services, at mes10@psu.edu.

If you have missplaced your health history form, you can get a copy of it here: http://studentaffairs.psu.edu/health/entranceRequirements/. Please make sure to print out both pages of the form and take it with you to your health care provider.

Should you have any questions about completing the form, please call Health Services at 570-675-9250 (in the summer, please call 570-675-9279).

 

Health Services
Suzanne Attanasio
Campus Nurse
ARB Room 119
(570) 675-9250
sua23@psu.edu

Hours:
Mon-Fri: 8am-4:30pm