Important Student Health Services Forms

These forms are used at Student Health Services. You may download and complete these forms and bring them to Student Health Services in order to receive an appointment or to receive an immunization.

Student Health History Form:

• Student Health History Form

Please complete all the requested information. You may attach a copy of your official immunizations record, i.e. copy from high school registrar, your doctor’s records, etc., instead of having a “Health Provider’s Signature”. Do not send your original records, send a copy. If you are seventeen years old and under, you must have your parent’s or guardian’s signature on the form as well as your signature. This Student Health History Form is required to be submitted to Student Health Services  prior to the beginning of the semester.


TB (PPD) Screening:

• Information Regarding Tuberculosis
• Tuberculosis Questionnaire

You will need to complete this questionnaire in order to receive a TB screening test. You must bring it to Student Health Services. The nurse will review this form and then will administer the TB.

History Taken Prior to Receiving Immunizations:

• History Prior to Immunization Form

This form will need to be completed when you are requesting an immunization shot. Please bring this form in to Student Health Services and the nurse will review the form and administer the immunization.
 

Release of Information From Medical Records:

• Release of Medical Records Form

All medical records are strictly confidential. Student Health Services will not release any information to anyone without your written consent. If you desire to have any or part of your medical records, you must complete the following request and submit this to Student Health Services. The nurse will review the records and tell you if there is a fee involved.


Women’s Health Clinic Intake Information:

You must complete and bring this form to Student Health Services in order to make an appointment in the Well Women’s Clinic. The nurse will review your paperwork and then she will schedule you for an appointment.

• Annual Women's Clinic Health History Intake Form
   

SHADES (Sexual Health Alcohol and Drug Education for Students):

This year UTSA Student Health Services received a federal grant to promote awareness of HIV, alcohol, and other drug abuse. SHADES was created under this grant with the goal to reach other students through presentations and programs, empowering students to make healthy life choices.

We are always looking for dedicated peer educators. If you think this might be for you, contact us to start the application and interview process. Click here to download the application.