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Includes under-18 parent consent, meningococcal and Hepatitis B vaccination disclosure per Ohio law, and a physician-completed immunization section for MMR, meningococcal quadrivalent, polio, varicella, and Tdap-related records.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/document/","Document",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/document/healthcare/","Healthcare",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/document/student-health-services-medical-history-meningococcal-hepatitis-b-vaccination-status/430259/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/student-health-services-medical-history-meningococcal-hepatitis-b-vaccination-status/430259.png","ImageObject",300,407,{"name":42,"@type":43},"Jordan Avery","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-30","2026-09-29",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",10,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"哪些人员需要填写并提交该医疗史与疫苗状态表？","Question",{"text":63,"@type":64},"表格要求学生/家长完成I–VII部分；同时含有一部分必须由医生完成。18岁以下学生需要家长或监护人签署同意相关治疗与程序。","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"表格中学生需要提供哪些基本健康信息？",{"text":68,"@type":64},"需要填写个人信息，并回答是否曾有或目前是否患有多类健康问题（如过敏、哮喘、心脏/肝脏问题、结核等），以及家族史相关项目。同时还需说明异常过敏反应、常用药物、既往严重疾病或受伤、以及是否接受过手术或住院。",{"name":70,"@type":61,"acceptedAnswer":71},"孟宁球菌与乙肝疫苗状态部分要求完成哪些内容？",{"text":72,"@type":64},"该部分要求学生（18岁及以上）或家长（18岁以下）阅读并理解相关说明，确认接种收益与风险，并勾选已接种或未接种孟宁球菌疫苗、乙肝疫苗，随后签名并填写日期。","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},430259,1790921286,{"code":4,"msg":82,"data":83},"success",[84,88,92,96,101,106,110,115,120,123,126],{"id":22,"doc_module":4,"doc_module_name":25,"category_name":85,"show_sort_weight":86,"slug":87},"Story & Novel",90,"story-novel",{"id":26,"doc_module":4,"doc_module_name":25,"category_name":89,"show_sort_weight":90,"slug":91},"Literature",80,"literature",{"id":33,"doc_module":4,"doc_module_name":25,"category_name":93,"show_sort_weight":94,"slug":95},"Exam",70,"exam",{"id":97,"doc_module":4,"doc_module_name":25,"category_name":98,"show_sort_weight":99,"slug":100},5,"Comic",60,"comic",{"id":102,"doc_module":4,"doc_module_name":25,"category_name":103,"show_sort_weight":104,"slug":105},6,"Technology",50,"technology",{"id":107,"doc_module":4,"doc_module_name":25,"category_name":29,"show_sort_weight":108,"slug":109},7,40,"healthcare",{"id":111,"doc_module":4,"doc_module_name":25,"category_name":112,"show_sort_weight":113,"slug":114},8,"Research & Report",30,"research-report",{"id":116,"doc_module":4,"doc_module_name":25,"category_name":117,"show_sort_weight":118,"slug":119},9,"Religion & Spirituality",20,"religion-spirituality",{"id":118,"doc_module":4,"doc_module_name":25,"category_name":121,"show_sort_weight":118,"slug":122},"World Cup","world-cup",{"id":55,"doc_module":4,"doc_module_name":25,"category_name":124,"show_sort_weight":55,"slug":125},"Lifestyle","lifestyle",{"id":127,"doc_module":4,"doc_module_name":25,"category_name":128,"show_sort_weight":97,"slug":129},19,"General","general",{"code":4,"msg":82,"data":131},{"doc_id":79,"user_id":132,"nickname":42,"user_avatar":133,"doc_module":4,"category_id":107,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":26,"language":139,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":140,"faqs":141,"seo_title":142,"seo_description":12,"update_tm":143,"read_time":97,"preview_page_count":4},1099523882367,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","STUDENT HEALTH SERVICES MEDICAL HISTORY  \nCheck One: o Undergraduate o Graduate o ESL o International Year of expected graduation/or length of stay   .  \nSECTIONS I-VII TO BE COMPLETED BY THE STUDENT/PARENT  \nI. Name   o M o F Date ofbirth   Place    \nLast First Middle City State Country  \nHome address   Phone   Height   Weight    \nNumber and street City State Zip Cell  \nParent, guardian or nearest relative   Phone        \nName Relationship Address Cell Home Work  \nFamily physician   Phone   Name Address  \nSpecialist  Phone   Name Specialty Address  \nII. Have you ever had or do you now have any of the following?  \n\n| Check each item | Yes | Year Check each item | Yes | Year Check each item | Yes | Year |\n| --- | --- | --- | --- | --- | --- | --- |\n| 1. Allergies (medicines, food, latex) |  | 10. Gastrointestinal problems |  | 19. Psychological counseling |  |  |\n| 2. Anemia |  | 11. Hearing loss/Recurrent ear problems |  | 20. Concussion / head injury |  |  |\n| 3. Anorexia/bulimia |  | 12. Heart disease |  | 21. Rheumatic/scarlet fever |  |  |\n| 4. Asthma |  | 13. Hepatitis |  | 22. Sexually transmitted disease |  |  |\n| 5. Attention deficit disorder |  | 14. High blood pressure |  | 23. Thyroid problems |  |  |\n| 6. Childbirth |  | 15. Kidney disease/stones |  | 24. Urinary tract infection |  |  |\n| 7. Depression or anxiety |  | 16. Meningitis |  | 25. Vision problems (contacts/glasses) or other |  |  |\n| 8. Diabetes |  | 17. Mononucleosis |  | 26. Tuberculosis |  |  |\n| 9. Epilepsy/seizures |  | 18. Pneumonia |  | 27. Other |  |  |\n\nIII. Family history (parent, grandparent, brother, sister) of the following?  \n\n| Check each item | Yes | No | Relation | Check each item | Yes | No | Relation |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n| Alcoholism |  |  |  | Mental health |  |  |  |\n| Diabetes |  |  |  | Tuberculosis |  |  |  |\n| High blood pressure |  |  |  | Sudden cardiac death |  |  |  |\n| Heart trouble |  |  |  | Other |  |  |  |\n\nIV. If you answered yes to questions of your health, give details along with corresponding number.  \nHave you ever had any abnormal ALLERGIC REACTIONS to any medications, foods or immunization (penicillin, serum, etc.)?  \no No o Yes If yes, explain  List any MEDICATIONS you take regularly (dose and schedule):  \nHave you ever had a serious illness (not listed) or injury? o No o Yes If yes, explain   Have you ever had surgery or been hospitalized? o No o Yes If yes, explain    \nV. HEALTH INSURANCE —IF YOU ARE CURRENTLY COVERED BY A HEALTH INSURANCE PLAN, PLEASE ATTACH A COPY OF YOUR INSURANCE CARD (FRONT AND BACK) . THIS ACTION DOES NOT FULFILL THE WAIVER PROCESS FOR THE XAVIER STUDENT HEALTH INSURANCE CHARGED TO THE BURSAR.  \nVI. UNDERAGE STUDENTS—Parent permission for treatment is required for Xavier students under age 18. IF YOU ARE UNDER 18 YEARS OF AGE, PARENTS MUST COMPLETE THIS SECTION: I hereby give permission for the Xavier University Student Health Services to render such diagnostic, therapeutic or minor operative procedures as they deem necessary for my son/daughter.  \nSigned   Date  / /  Parent or guardian  \nRETURN TO: Xavier University, Student Health Services, 3800 Victory Parkway, Cincinnati, Ohio 45207-7611  \nPhone 513-745-3022 | Fax 513-745-3563 | Return by August 1  \nVII. DISCLOSURE OF MENINGOCOCCOL AND HEPATITIS B VACCINATION STATUS —per Ohio Revised Code, section 3701.133,(B) . Must  \ncomplete if you will be living in a campus residence. I, The undersigned student (if 18 years of age or older) or parent (if student is under 18), have read and understand the information provided to me about Meningococcal Meningitis and Hepatitis B. I understand the benefits and risks of being vaccinated against these diseases. The information below regarding my/my student’s vaccination status is accurate.  \nMeningococcal vaccine received: o Yes o No Hepatitis B vaccine received: o Yes o No  \nSigned   Date  / /  Student/Parent or guardian (if student is under 18)  \nTHIS SECTION MUST BE CO","cbCaibbnfXUY4SVB","https://ap.wps.com/l/cbCaibbnfXUY4SVB","pdf",318845,"English","# Student Health Services Medical History\n## Student/Parent sections I–VII\n## Physician-completed immunization requirements","[{\"question\":\"哪些人员需要填写并提交该医疗史与疫苗状态表？\",\"answer\":\"表格要求学生/家长完成I–VII部分；同时含有一部分必须由医生完成。18岁以下学生需要家长或监护人签署同意相关治疗与程序。\"},{\"question\":\"表格中学生需要提供哪些基本健康信息？\",\"answer\":\"需要填写个人信息，并回答是否曾有或目前是否患有多类健康问题（如过敏、哮喘、心脏/肝脏问题、结核等），以及家族史相关项目。同时还需说明异常过敏反应、常用药物、既往严重疾病或受伤、以及是否接受过手术或住院。\"},{\"question\":\"孟宁球菌与乙肝疫苗状态部分要求完成哪些内容？\",\"answer\":\"该部分要求学生（18岁及以上）或家长（18岁以下）阅读并理解相关说明，确认接种收益与风险，并勾选已接种或未接种孟宁球菌疫苗、乙肝疫苗，随后签名并填写日期。\"}]","Student Health Services Medical History - Meningococcal & Hepatitis B Vaccination Status | PDF",1790652315]