Medical History Form

Welcome to Pittsburg State University!
IMPORTANT: Pittsburg State University requires all new students to complete a MEDICAL HISTORY FORM as part of their enrollment process. This health information is strictly confidential and can be very valuable should you have a medical emergency while a student on campus. Completing and returning your medical history form NOW will expedite your health care at a later date.

Pittsburg State University does not have a required immunization policy prior to enrollment, but we do follow the American College Health Association's recommendations for appropriate vaccinations for persons entering college. It is very important that your immunizations be CURRENT AND ON RECORD. There is a place on the Medical History form for you to complete this information. Immunizations are available at the Student Health Center upon request. Be sure the dates are completed.

Return the Medical History Form along with your other enrollment information to the Office of Admission, Pittsburg State University, 1701 S. Broadway, Pittsburg, KS 66772-7520 or fax each side of form separately and send to 620-235-6003. If you have any questions regarding the form or our services, feel free to contact us by phone at 620-235-4450.
Click on the link below for a PDF version to download and print (uses Adobe Acrobat)

Medical History Form

Notice of Privacy Practice

Pittsburg State University Student Health Services remains committed to protecting the confidentiality of the health information that is generated as a result of utilizing our services.
Due to recent changes in the law, all patients will be presented with a Notice of Privacy Practices that describes our responsibilities and the patient's rights regarding the use and disclosure of the protected health information.
Effective April 14, 2003, each patient will be asked to sign a document that acknowledges the receipt of this notice and provide us with consent to operate accordingly.
View the Notice of Privacy Practices.
You will need Adobe Acrobat reader click here to download Acrobat.
If you have questions, please contact our Privacy Officer, Mary Carol Pomatto, at (620)-235-4102.