Medical Record Form

All undergradute students are required to submit a completed medical record form in its entirety plus a record of immunizations upon admission to the University. Any student who has had a break in matriculation of two or more semesters must resubmit the same. All students participating in Hampton University-sponsored special summer programs are required to submit completed medical forms and a record of immunizations. This does not apply to regular summer session students.

Physical examination (part iii - vi) must be submitted on the university form. Faxed copies of the medical record form are not acceptable. Please make a copy of medical form for your records.

Download the Health Center Medical Record Form  (3 pages)

Download links marked with the Adobe Acrobat logo require Adobe Acrobat Reader. You can download Acrobat Reader for no charge by visiting http://get.adobe.com/reader/.