Wellesley College Health History Form

student’s name:Immunizations Required by MA law for Wellesley College Entry**use this form only if electronic copy of complete & signed immunization record from clinician is unavailable **dob: (mm/dd/yy)Page 7Tetanus-Diptheria-PertussisCompleted Primary Series required (date of final dose of DTP/Dtap)Date (mm/dd/yy): ________________ANDTdap booster required within the past 10 years Tdap Date:______________(if no Tdap, Td booster within 5 years is acceptable) Td Date: _____________Measles, Mumps, Rubella (MMR)Combined MMR- 2 doses required:Dose 1 given on or after 12 months of ageDate (mm/dd/yy): ________________Dose 2 given at least 4 weeks after first doseDate: _____________ORSerologic Titers (MUST provide copy of lab report)Measles ❏ Immune ❏ Not Immune Date:______________Mumps ❏ Immune ❏ Not Immune Date:______________Rubella ❏ Immune ❏ Not Immune Date:______________VaricellaVaricella- 2 doses requiredDose 1 given on or after 12 months of ageDate (mm/dd/yy): ________________Dose 2 given at least 4 weeks after first doseDate: _____________ORSerologic Titers (MUST provide copy of lab report) ❏ Immune ❏ Not Immune Date:______________ORHistory of Chickenpox diseaseHepatitis BFull 3 dose series required for all studentsSpecify if 2 adult dose alternate series givenORSerologic Titers for Hepatitis B Surface Antibody (MUST provide copy of lab report)Hepatitis B ❏ Immune ❏ Not ImmuneDate (month/year):________________Hep B Dose 1 Date: _____________Hep B Dose 2 Date: _____________Hep B Dose 3 Date: _____________Meningococcal VaccineMenactra- Meningococcal Conjugate VaccineDate: _____________(2 doses preferred if dose 1 given at age 11-12) Date: _____________ORMenomune-Meningococcal Polysaccharide (must be within 5 years)Date: _____________ORSigned Waiver Attached (see page 9)Date: _____________Other Immunizations Date Dose #1 Date Dose #2 Date Dose #3hepatitis ahpv (gardasil)poliorabiestyphoid (injectable)typhoid (oral)japanese encephalitisyellow feverother: (ie: flu)Clinician’s Signature:____________________________________________________________________________________(M.D., N.P., P.A.) (not parent clinician)DATEPlease print name & address if different from page 3