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Health History, Physical and Immunization Form

Policy:  All undergraduate and graduate students are expected to submit a completed Health History Physical & Immunization Form to the Student Health Services Office. Students who choose to use the Health Center must complete a Health History, Physical and Immunization Record before non-emergency services can be provided. Resident students who do not submit the completed Health History Record may be required to live off campus. (Approved by the Board of Trustees 2000).

It Is The Law: The Pennsylvania State Legislature passed a meningitis vaccination law in 2002 pertaining to students residing in residence halls. This legislation requires that all students residing in a residence hall in Pennsylvania be vaccinated for meningococcal meningitis before moving onto a college campus, unless they have signed a waiver after receiving information about the disease and the benefits of the vaccine.   

Medical Records Request Form

  • Medical records will only be e-mailed to your Marywood E-Mail Account, unless you are a non-marticulating student.
  • We strongly recommend that you make a copy of these records or save them to your hard drive for all future requests that you may receive.


To obtain your records please follow the instructions below:

  1. Print and complete the following form: Medical Records Release Form. BE SPECIFIC WITH YOUR REQUEST, as this is the only information that can be sent.
  2. Fax the completed form to 570-961-4735.
  3. Send a note via e-mail to pdeschaine@marywood.edu with a notation in the subject line medical records request.
  4. Your records will be e-mailed to you within two weeks.

  5. Before turning your records over, be sure to make copies for your personal file.