Health Form Instructions

Instructions for Completing Your Health Form

*Mailing address:
Baylor University Health Services
Attn: Health Form
One Bear Place #97060
Waco, TX 76798-7060

*Fax: 254-710-2499

*Email: Health_Services@baylor.edu

1. Fill out your demographic data in the first section. Make a copy of the front and back of your health insurance card and send with the health form.
2. Fill out your medical history, including explanations of positive answers and all medications that you take regularly.
3. Sign and date the form. If you are under 18, have your parent or guardian sign and date it also.
4. Fill in dates for the required immunizations for Baylor.  Also attach a copy of your official immunization record (school record or doctor’s office record with healthcare personnel signature).  If you do not have an official record, healthcare personnel must sign your Health Form to authenticate the immunization dates.
5. Answer the 4 questions regarding possible tuberculosis exposure. If any of the answers is “yes”, you will need to go to your doctor or a public health department to have tuberculosis testing done. Either a skin test or blood test is acceptable. If the skin test is positive, you may choose to just have the chest x-ray and discuss with your doctor about being treated with INH or rifampin. You may also choose to have a blood test to make sure the skin test is accurate. If the blood test is negative, you do not need a chest x-ray. This section needs to be filled out completely and signed by a healthcare provider.
6. Please keep a copy of your Health Form for your records.
7. Please return this form by fax, email, or mail

Health Form