Student Health Forms
New Students: Immunization and Health History Forms
The student code of conduct requires that all students submit a record of their immunizations and health history. These forms do not require a physical exam; they are simply a health history. You must submit these two forms before you can register for classes.
Please open and complete forms, print, and mail or fax to the Health Service. (Fax number and address are on the forms.)
Some personal computers have software programs that permit saving the completed documents. Completed & saved documents (and scanned proof of immunization) can be sent electronicaly to: email@example.com
Immunization Form : Must have Health Care Provider Signature on form or official documentation attached. (Attach written proof of dates of immunization from one of the following: Official School health record, Physician record on letterhead, International Health Certificate, Official state certificate, Health Passport, Baby Book.) cited: Pennsylvania Department of Health State Immunization Code 23.82
Enrolled students may access additional Duquesne University Health Service forms through DORI (under Student Resources)
Complete this form only if you have been directed to do so by your individual school or program. (This is not required for all new students.)
Pre-Clinical Health Requirements Form (Pharmacy & Graduate Nursing)
All Pharmacy prior to their professional phase (generally 2nd to 3rd year), and Nursing (GRADUATE ONLY) Students should review the form as they must meet the additional requirements listed on it.
Rangos Health Science students ONLY must complete the following :
If you aren't sure if you should complete this form, please call the Coordinator for Pre-Clinical Requirements, 412.396.1652.
Some personal computers have software programs that permit saving the completed documents. Completed & saved documents can be sent electronicaly to: firstname.lastname@example.org