Health History

There are additional immunization requirements for some majors (including education, nursing, physician assistant and international rescue and relief).
Parents or Guardians
Personal Health Questions
Ear, Nose, and Throat
YesYes, less than 1 year agoNo
Trouble with hearing?
Severe difficulty breathing through your nose?
Frequent sore throats or colds?
YesYes, less than 1 year agoNo
Need of eye glasses or contact lenses?
Loss of vision or damaged function in one or both of your eyes?
YesYes, less than 1 year agoNo
Gum or tooth trouble?
YesYes, less than 1 year agoNo
Loss of or damaged functioning of a lung?
YesYes, less than 1 year agoNo
A heart murmur that the doctor said is serious?
High blood pressure?
Rheumatic fever?
YesYes, less than 1 year agoNo
Consistent pain in the abdomen?
Frequent episodes of vomiting?
Trouble with gas, heartburn, sour stomache, bloating, or indigestion?
Stomach or duodenal ulcers?
Recurrent diarrhea?
Jaundice or Hepatitus
Any serious or disabling stomach or bowel problems?
YesYes, less than 1 year agoNo
Damaged function of a kidney
Frequent infections in the kidney or bladder?
Sexually transmitted disease or infection?
Frequent urination?
Irregular periods (Women only)?
Severe cramps (Women only)?
Excessive flow (Women only)?
Any medicine for menstrual problems (Women only)?
YesYes, less than 1 year agoNo
An over-active thyroid?
An under-active thyroid?
YesYes, less than 1 year agoNo
A nervous breakdown?
Hospitalized for problems with your nerves?
Seizures in the past 5 years?
Recurring severe headaches?
Blackout spells (or episodes of confusion)?
YesYes (>1yr ago)No
Back stiffness or pain which interferes with your normal activity for more than 7 days?
Troublesome joint stiffness, pain or swelling?
Rheumatoid arthritis?
An amputation of an arm or leg?
YesYes, less than 1 year agoNo
Troublesome acne?
Persistant or recurrent skin rash?
Mole(s) that change in size or color?
YesYes, less than 1 year agoNo
Serious blood reaction to a drug treatment?
YesYes, less than 1 year agoNo
Do you feel lonely or depressed most of the time?
Do you feel pressured most of the time?
Have you seriously contemplated or recently attempted suicide?
Have you obtained help from a mental professional?
Have you refused mental health help?
Do you feel you have serious nervous or emotional problems?
Would you find counseling useful for any of your problems?

When significant emotional problems are evident, the admissions committee will be informed. Records and advice may be needed from your previous health care providers. If adequate facilities (consistant with the principles of our religious denomination) do not exist at the college or in the community should continued care be needed, recommendation will be made for other schools where your needs may be more adequately met.

General Medical
For any prescription medicine (shots) which you wish the Health Service to administer to you, you must bring a written order signed by your physician. This order must name the medicine and must include the amount to be given, the frequency and method of administration, and how long this medication is to be continued.
Has a physician told you that you should have an operation that you still need?
Are you sensitive to any drugs?
Other allergies?
Childhood diseases
Measles (Red)?
Measles (German)?
Scarlet Fever?
General Profile
Immunization Records

REQUIRED DOCUMENTATION: You must show proof of the following vaccines:

  • MMR (Measles, Mumps and Rubella) two vaccines after the 1st birthday or a lab titer proving immunity. 
  • A negative tuberculosis (TST) skin test within the past year is required for all international students (or students born outside of the United States).
  • Meningococcal vaccines (2 shots) or a waiver form signed if living in the residence hall (must be signed by parent if student is under 19 years old).

Additional Recommended Vaccines*:

  • Tetanus (Tdap) to be within the past 10 years
  • Polio series (3-5 shots)
  • Varicella (chickenpox) vaccines (2 shots) or Varicella lab titer proving immunity.
  • Hepatitis B series (3 shots)

*Students traveling internationally—in addition to students in the physician assistant, nursing and international rescue and relief programs—are required to have these vaccines.

You can submit these documents by faxing (402.486.2564), emailing scans (studenthealth [at] or mailing copies (3800 S. 48th Street; Lincoln, NE 68506).