Medical History Form

Welcome to Drake University from the American Republic Student Health Center. Enclosed is the Medical History and Immunization Record required for full time admission to Drake University. We encourage you to either bring the PINK forms to orientation and give to health center staff, or mail them to the Student Health Center.  If you were a Drake student in the past, please call the Student Health Center before completing this form. Students not completing the Immunization Record and Medical History will be placed on HOLD status after the 2nd week of classes.  (Withholding grades and inability to register for the following semester).

Admission Requirements:

Medical History Form:

• Part I  REQUIRES copies of your immunization records:
  TWO MMR Vaccinations (Measles, Mumps and Rubella).  If you are unable to get the vaccine prior to coming to Drake, the vaccine is available at the Health Center for a fee.
• Part II  All students need to answer the questions regarding tuberculosis.  If you answer yes to any questions, you need a Tuberculin test.
• Part III . 1) Show documentation of meningococcal vaccine or 2) sign a waiver that indicates they have been provided educational materials but have chosen not to receive the vaccine at this time.

Strongly Recommended

• Tetanus/diphtheria booster within the past ten years.
• Varicella vaccine is recommended if you have not had the chickenpox.
• Hepatitis B, a series of three injections. If the series is started, it can be completed at the Student Health Center.
• Meningitis vaccine protects against meningococcal meningitis. This vaccine is highly recommended for freshmen living in dormitories. This is available at the Student Health Center. Please sign the waiver on part III of the medical history form if you are not getting the vaccine at this time.
• Polio, a total of four doses, the last one given after 4 years of age.
• Annual influenza vaccine given in the fall. (Offered on campus each fall).

Cost

The majority of services are provided at no charge, call to inquire about costs for specific services.  Immunizations are offered for a fee.  Laboratory tests that are not performed at the Health Center are sent to Iowa Methodist Hospital laboratory and are to be paid by the student.  The Health Center does not submit fees for insurance billing/reimbursement.

Insurance

Completion of the medical history form does not waive the mandatory Drake Health Insurance.

Students do not have to provide insurance information in order to be seen at the Health Center.  Since most students are “out of area” on their insurance plans, it is helpful to know what coverage you have in Des Moines.  It is important to have a copy of your insurance card in case you need to see a specialist or in the event of an emergency. It is also important to know the prescription coverage provided by your insurance while you are in Des Moines.  Verification of health insurance will be required by the college. 

Confidentiality

If you are 18 years of age or older, you are considered an adult and your health information is confidential. The Student Health Center personnel is unable to give out information concerning your health to anyone, including your parents, without your written permission.

Services at the Student Health Center are available for full- time students only by appointment. The American Republic Student Health Center is located at the corner of 32nd and Carpenter.

Please feel free to call if you have questions, 515-271-3731