91ÇÑ×Ó

Health History Form

You may also download the Health History form to print, fill out, and send back to us. Forms should be emailed to healthcenter@smu.edu or mailed to the following address: 
Dr. Bob Smith Health Center
P.O. Box 750195
Dallas, Texas 75275-0195

If you are under the age of 18, include your Parent/Guardian Name and Email address on the form. A Parent/Guardian is required to sign the form of any student under the age of 18. The Parent/Guardian will receive notification via the email provided to electronically sign the form. Please note: The form will not be submitted until after the Parent/Guardian signs the form.

Vaccination Requirements

All incoming students must comply with the following vaccination requirements. Attach official immunization record to the electronic Health History form or download the form and send a completed copy to your doctor for signature and stamp. Email signed forms to healthcenter@smu.edu.

1. Meningitis vaccine (Menactra, Menveo, or MCV4) administered within the past 5 years. Texas State Law requires a meningitis vaccine for new students under the age of 22. Students over the age of 22 are exempt from this requirement. Proof of vaccination (or booster shot within the last 5 years) must be submitted to the Dr.Bob Smith Health Center prior to registering for classes.
2. Two doses of the Measles, Mumps, and Rubella (MMR) vaccination.

If you answer yes to any of the TB screening questions on the Health History form, the results of a TB Skin Test within the past 6 months is required. Attach official TB Skin Test results to the electronic form or email to healthcenter@smu.edu.

Allow a minimum of seven (7) business days for delivery if mailed from a location within the United States and two (2) business days if electronically submitted or emailed. If possible please submit at least two (2) weeks prior to your orientation/registration. 91ÇÑ×Ó is not responsible for forms not received due to mail misdirected or lost in transit. Incomplete or illegible submissions cannot be processed.

• For verification. You may check your my.91ÇÑ×Ó account after submitting your Health Form to verify receipt and completeness by going to: my.91ÇÑ×Ó Student Homepage > Health Center > Health History.
• If you have any questions please email us at healthcenter@smu.edu, please include your name and 91ÇÑ×Ó ID number.

The Dr. Bob Smith Health Center may provide vaccinations or a TB Skin Test, please contact the health center at 214-768-2141 for more information.

Allergy Injections

We can administer allergy immunotherapy prescribed by an outside doctor. Injections can be continued on a schedule that has been established by your allergist or treating physician. Our guidelines require several pieces of documentation in order for our staff physicians to supervise the injections:

1. The name, address, phone and fax number of your treating physician.
2. An antigen injection schedule - this should include an area to record the date, antigen, dilution, dosage and injection site.
3. Antigen administration instructions - any routine or special instructions for our nursing staff should be included here.
4. Instructions for missed doses, local or systemic reactions.
5. A copy of the note from your last clinic visit with your physician.

We will require these five pieces of documentation for all students who wish to receive continuous allergy immunotherapy at the Dr. Bob Smith Health Center. Initial injections should be given at your own physicians’ office. The health center will not initiate immunotherapy. If a student has an allergy gap of greater than 60 days, they should visit with their private physician prior to receiving an injection at the Health Center.

Download the Allergy Injection Release Form