N E W Y O R K M E D I C A L C O L L E G E A M E M B E R O F T H E T O U R O C O L L E G E A N D U N I V E R I S T Y S Y S T E M

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1 N E W Y O R K M E D I C A L C O L L E G E A M E M B E R O F T H E T O U R O C O L L E G E A N D U N I V E R I S T Y S Y S T E M HEALTH SERVICES BASIC SCIENCES BUILDING VALHALLA, NEW YORK TEL FAX HEALTH_SERVICES@NYMC.EDU TO: School of Medicine, Incoming class of 2022 FROM: Marisa Montecalvo MD, Director, Health Services DATE: February 12, 2018 RE: Health Service Requirements Welcome to New York Medical College. The requirements delineated on page 2 of this letter and the Health Services forms must be completed and returned by Friday, June 15, Please read the following carefully: 1. Send the completed Health Services packet and required documentation to NYMC by mail or by FAX. See address and FAX above. ed documents are NOT accepted. 2. DO NOT send in partially complete information. 3. Students with incomplete health records will not be allowed to register for classes. 4. To prepare for these requirements, please do the following NOW: a. Schedule an appointment with your physician for a physical and blood tests. b. Perform blood tests for the required titers needed. c. If your blood tests (titers) indicate a lack of immunity, follow up with your physician for any required booster vaccine and send that documentation to us. Page 1 of 2

2 N E W Y O R K M E D I C A L C O L L E G E A M E M B E R O F T H E T O U R O C O L L E G E A N D U N I V E R I S T Y S Y S T E M HEALTH SERVICES BASIC SCIENCES BUILDING VALHALLA, NEW YORK TEL FAX HEALTH_SERVICES@NYMC.EDU Medical History (pg. 2 forms) Physical Exam (pg. 3-4 forms) Tuberculosis (TB) Screening (pg.4 forms) Hepatitis B virus (HBV) Immunity Measles, Mumps Rubella Immunity Varicella Immunity Tetanus, Diptheria, Pertussis Polio Vaccine Records release ( pg. 5 of forms) Meningococcal Vaccine (pg. 5 of forms) Health Services Requirements = Completed by student and reviewed by healthcare provider. Must be within 1 year of school start date and signed by a licensed provider. A tuberculin skin test (TST) or interferon gamma release assay (QuantiFERON - TB) within one year of school start date. If either is positive: Chest x-ray performed after the test was positive. Provide dates of TB treatment or indicate Full series (3 doses) of HBV vaccine PLUS Positive QUANTITATIVE HBV surface antibody (>10). Non-responders are to receive a booster HBV vaccine and retested 30 days later or show evidence of natural disease. Beginning on or after age one: 2 MMR (at least 28 days apart), or 2 measles, 1 mumps and 1 rubella vaccine OR Lab test with positive antibody to measles, mumps & rubella Documentation of two varicella vaccines OR Lab test with positive antibody to varicella. A booster within ten years. One booster as an adult is to include acellular pertussis (Tdap). Last polio booster date. Signed release of records form Provide vaccine records MCV4 or MenB if received. Completed and signed attestation Done Page 2 of 2

3 Last Name/ First Name: Touro ID: New York Medical College A MEMBER OF THE TOURO COLLEGE AND UNIVERSITY SYSTEM Health Services History and Physical Medical School Student (check school) Graduate School of Basic Medical Sciences Accelerated Master s Program Master s Program PhD School of Health Sciences and Practice Department of Physical Therapy Speech and Language Pathology Dental School Employee Department: Job Title: Class Year: Date of Hire:

4 GENERAL INFORMATION: Last Name First Name Date of Birth Sex (M,F) address Local Address City State Zip Cell # ( ) Home# ( ) Country of Birth (Country) Father s Name Mother s Name Physician s Name Physician Location (City, State): Physician s Phone ( ) Health Insurance Co. Policy ID# Emergency Contact Relationship Home phone # Cell phone # Work phone# PAST MEDICAL HISTORY: (Circle if applicable) Surgeries: (List year, procedure): Hospitalizations: (List year, reason): Active acute or chronic medical conditions: (Indicate illness & specify if ongoing): History of mental health disorder? (Please specify and indicate if receiving on-going care): Current medications: Allergies to medications food or other substances: FAMILY HISTORY: List disease and relationship: (ie: parent, sibling, maternal/paternal grandparent) 2

5 Last Name/ First Name: PERSONAL and SOCIAL HISTORY Have you ever smoked? (circle) Yes / No; If Yes: # packs per day No. of years smoking: Do you now or have you ever habitually used drugs or alcohol? (circle) Yes/No: Have you lived outside the US in the past 5 years: (circle) Yes / No If yes: Country: REVIEW OF SYSTEMS: Please indicate if you have / had any of the conditions below: General: weight gain / weight loss GI: constipation, diarrhea, rectal bleeding, stomach pains, hepatitis, other Skin: rashes / other changes GU: blood in urine, testicular lumps, other HEENT: head injury / hearing disorder GYN: abnormal menses, other Neck: swollen glands, thyroid disorder Blood or Immune disorder: specify: Lungs: wheezing, infections, other Neuro: headaches, seizures, vision disorder Cardiac: high blood pressure, cardiac disorder Skeletal: Joint pain, back problems, other: Endocrine: diabetes, thyroid disorder, other Applicant Signature: Date: HEALTH CARE PROVIDER PHYSICAL EXAMINATION: Date of Exam: / / (N=Normal) Height: Weight: Temperature: Pulse: Blood Pressure: SKIN: N LYMPHATIC: N ENT & NECK: N ABDOMEN: N LUNGS: N EXTREMITIES: N HEART: N MUSCULOSKELETAL: N BREASTS / TESTICLE(S): N NEUROLOGIC: N 3

6 Last Name/ First Name: TUBERCULOSIS (TB) SCREENING HISTORY: Any past tuberculin skin test (TST) or blood test Quantiferon Gold to detect TB? Yes /No Date of last TST: / / Date of blood test Quantiferon Gold : / / Test Result: (TST mm ) If positive, date of most recent chest x-ray: / / ( include a copy of chest x-ray report) Was the patient treated for latent tuberculosis: If yes, medication taken: Date Treatment started: / / Number of months treated: ASSESSMENT: Please indicate below: The applicant is in good physical and mental health. The applicant has the following health condition(s) for which the continuation of care is required: Please provide a complete description of the care required: Except as noted above, the applicant is in good physical and mental health and has no problem that might interfere with their ability to perform professional studies / new position. Health Care Provider (Print Name) State and License Number Health Care Provider s Signature Date Telephone Number For Tuberculosis Screening: TST Planted Date: ID R L Inner Forearm Lot# Exp. Date TST Read Date: Results in mm: Read by: 3/1/17 4

7 New York Medical College A Member of the Touro College and University System Health Services, Basic Sciences Building Valhalla, NY Tel Fax Release of Records I hereby give my authorization to the New York Medical College Health Services Office to release my records required for future rotations at hospitals and clinical sites during my education here at NYMC. I understand that in order to be a student on rotation in these medical institutions, it is mandated by New York State Law that each hospital has on file a copy of my records in order to show proof of proper immunizations. Print Name: Signature: Date: Meningococcal Vaccination To be completed and signed by student: (check one box and sign) I had meningococcal immunization: Date of vaccine: I have read, or have had explained to me, the information regarding meningococcal meningitis disease. I understand the risks of not receiving the vaccine. I have decided that I will not obtain immunization against meningococcal meningitis disease. For more information visit CDC s meningococcal disease website at: Signature: Date: Release & Meningococcal Form 02/22/2017 dh 5