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Health Form and Immunization Record Form - Midlands Technical - midlandstech

Health Form and Immunization Record Form - Midlands Technical - midlandstech 2026

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The document is a Student Health Form for applicants to the Nursing Program at Midlands Technical College. It requires students to provide personal information, past medical history, and undergo a physical examination by a healthcare professional. The form includes sections for medical history, diagnoses, surgeries, medications, and restrictions on physical activity. Additionally, it outlines mandatory immunizations and tests required before entering the program, emphasizing the importance of completing the health form accurately and submitting it within specified deadlines.

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Click ‘Get Form’ to open it in the editor.
Begin with Section I by entering your personal information, including your name, address, and contact details. Ensure all fields are filled accurately.
In Section A, check the boxes for any past medical history that applies to you. If you answer 'YES' to any questions, be prepared to provide details on the next page.
Complete Sections B through E by providing necessary information about diagnoses, surgeries, medications, and any physical activity restrictions.
Section II requires a physician's examination. Ensure your healthcare provider fills this out completely and signs where indicated.
For the Immunization Record section, list each required vaccine along with dates and signatures from your healthcare professional confirming immunity.

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Versions	Form popularity	Fillable & printable
2013	4 Satisfied (55 Votes)
2008	4.9 Satisfied (30 Votes)

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Do you need a doctors order for vaccines?

The date the vaccine is administered. The name, office address, title and signature (electronic is acceptable) of the person administering the vaccine. Initials of the vaccine administrator will suffice as long as the office keeps a record of the person to whom the initials refer.

How to submit immunization records to UB?

Submit a copy of your immunization records from a previous school or your health care provider. (Must be on official letterhead; copy from doctor must be signed and include office address and phone. Many medical practices or previous schools have an online portal you can use to print an official copy to send to UB.)

Who can administer vaccines in New York?

Getting a vaccine at a doctors office or health department does not require a patient-specific prescription from another health care provider.

Who can fill out my immunization form?

Should students or student health offices complete the form? Students should complete the AAMC Standardized Immunization Form in conjunction with either the student health office at their medical school or with their primary care provider.

What counts as proof of immunization?

Photocopies of immunization records from a licensed healthcare provider or clinic, or from a California K-12 school uploaded to My Health Portal. All records must show the vaccine type, dose, and date of each shot.