Prior to starting at the University of the Pacific, there are several health clearance requirements that need to be completed.

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1 Academic Year 2018/2019 Dear Dental Student: Please read this packet carefully. It contains critical information for your success as a student. It is our pleasure to welcome you to the University of the Pacific and to introduce you to Student Health Services. We provide student-centered primary care to Pacific students, promote optimal wellness, and assist students to achieve their academic goals through quality health services. Some highlights about our services: All students who pay the Cowell Wellness fee may access all services regardless of their insurance coverage. Student Health Services offers: o Primary care with referral service as needed Physicals o Immunization review and administration TB screening and testing o Preventive screenings Women s care o Contraceptive services STI testing and treatment o Online medical portal o Dietitian Services (phone based) o Nurse Advice line when we are not open ( option 4) Additionally, Student Health Services monitors student health and communicable disease clearance and compliance. Prior to starting at the University of the Pacific, there are several health clearance requirements that need to be completed. A check-list with requirement deadlines and several required documents are enclosed in this packet for your convenience. Thank you and we look forward to providing physical and mental health services to you.

2 CHECK- LIST FOR STUDENT HEALTH SERVICES UPLOAD DOCUMENTS Due June 21, 2019 Under the Medical Clearances tab: go.pacific.edu/myhealth History & Physical Physical exam must be completed by a provider. Copy of immunization card(s) and immunization lab report(s) See Health Requirements form You may also mail documents to: Student Health Services 3601 Pacific Avenue Stockton, CA ONLINE ITEMS Due June 21, 2019 Under the Medical Clearances tab: go.pacific.edu/myhealth Acknowledgement of Receipt of Notice of Privacy Practices Acknowledgement of No Show Cancellation Policy & Fee Schedule Patient Lab Service Policy Health history questionnaire ONLINE ITEMS Due July 27, 2018 Under the Insurance Waiver tab: go.pacific.edu/myhealth Yearly Insurance Waiver Waiver completion is required to avoid being charged the Student Health Insurance Premium. Completing the previous health-related items DO NOT satisfy the waiver requirement. You will need to complete a new waiver each fall term. Consequences for Non-Compliance Program Level Students may be removed from classes or experiential learning opportunities until compliant. University Level Students who fail to complete the requirements by October 15, 2019 will have a hold placed on your registration account.

3 HEALTH REQUIREMENTS Dental Students (Acceptable documentation includes copies of childhood immunization records, immunization records/printouts from a provider, and/or lab reports.) Name Student ID # Birthdate DDS IDS AEGD Endo Oral Surg. Ortho Required: History and Physical Examination o Must be completed after March 1, (See Page 4&5) Hepatitis B Surface Antibody Lab Result o Quantitative Hepatitis B Surface Antibody blood test showing a positive immunity (required even if you have 3 vaccines) MMR (Measles, Mumps, Rubella) Series o Two documented doses OR lab result documenting a positive immunity Tdap Vaccine (Tetanus, Diphtheria, Acellular Pertussis) o One documented dose in the last 10 years (Td will not be accepted) o Tetanus booster should be given if the last Tdap was 10 years ago and is now expired o Blood work for Tdap is not acceptable Varicella Vaccine (Chickenpox) Series o Two documented doses OR lab result documenting a positive immunity o History of disease is not acceptable Tuberculosis Screening (Page 6) o o No history of positive PPD test or disease 2-step PPD screening within 3 months of matriculation (Two placements required. Second placement should be placed within 1-3 weeks after first placement) History of positive PPD or disease Chest X-ray, Quantiferon Gold or T-Spot blood tests within 6 months of matriculation if history of positive PPD test or disease. If blood test results are positive, chest x-ray results must be provided. Documentation of previous BCG vaccination, Latent TB treatment or Active TB treatment, as applicable. Recommended Influenza Vaccine o To be announced in Fall Upload Records: go.pacific.edu/myhealth under the Medical Clearances tab Mail Records: Student Health Services, University of the Pacific 3601 Pacific Avenue Stockton, CA

4 HISTORY AND PHYSICAL (General or Entrance) To be signed by: Physician, Nurse Practitioner or Physician s Assistant. STUDENT S NAME: DATE: DATE OF BIRTH: SEX: STUDENT ID #: ADDRESS WHILE ATTENDING DUGONI: PHONE NUMBER: DDS IDS Ortho AEGD Endo Oral Surgery PAST MEDICAL HISTORY: 1. Significant past health problems, major illnesses/injuries, surgeries, hospitalizations: 2. Childhood Diseases: 3. Medications (Prescribed, Vitamins, Supplements, OTC) within the last 3 months: 4. Drug allergies & reactions: FAMILY HISTORY: 1. Parents: 2. Siblings: SOCIAL HISTORY: 1. Employment: 2. Exercise program: 3. Dietary Patterns: SUBSTANCE USE: Alcohol: Tobacco: Recreational Drugs: REVIEW OF SYSTEMS: General: Skin: Head: Eyes: Ears: Nose: Throat: Mouth: Page 1 of 2

5 NAME: ROS: Breasts: Resp: CV: GI: GU: ID #: Ob/Gyn: MS: Neuro/Psych: Heme/Lymph: Endo: Other: PHYSICAL EXAMINATION: Ht Wt BMI BP Pulse Resp Temp Visual Acuity Right 20/ Left 20/ Both 20/ uncorrected corrected Sexually Active: Yes No Number of Children: (Write N/A if item does not apply to student) GENERAL/Mental Status: SKIN: HEAD: EYES: EARS: NOSE: THROAT: NECK: LUNGS: CV: ABD: EXT: NEURO: GU MALE: LAST PELVIC RESULT: DATE: BREASTS: ASSESSMENT AND PLAN: 1. Health recommendations: 2. Please review the student s immunization status, provide the necessary vaccines and/or titers to complete entrance requirements. Please provide documentation of immunizations. 3. Please review the student s TB status, administer the appropriate TB screening and provide appropriate documentation of TB clearance to complete entrance requirements Signature of Provider/Printed Name License # Date Address of Provider (Stamp preferred) Phone/Fax Numbers Page 2 of 2

6 TUBERCULOSIS (TB) SCREENING 1. Have you had a positive TB (or PPD) test? a. If NO, start 2 step PPD protocol (step #2&3) b. If YES, a Chest x-ray, Quantiferon, or T-spot must be completed within 6 months of matriculation. Tuberculosis Questionnaire Form must be completed. Turn in documentation of INH treatment (INH treatment involves taking medicine for 6 months to 9 months after a positive test). If blood test for Quantiferon or Tspot is Positive, a Chest x-ray is required. 2. Administer PPD#1 (Reading must be read within hours of placement) a. If result is negative, go to step #3. b. If result is positive, a chest x-ray is required. Complete Tuberculosis Questionnaire. Discuss INH treatment with your provider. 3. Administer PPD#2 (Administer one week after and no more than 3 weeks after first placement) a. If result is Negative, you are compliant. b. If result is positive, a chest x-ray is required. Complete Tuberculosis Questionnaire. Discuss INH treatment Student Name: Student ID#: DOB: First PPD Date administered / / Date read / / mm Positive Negative Second PPD Date administered / / Date read / / mm Positive Negative Name & Title Signature Chest X-ray (Attach Result) Date / / Result: Positive Negative Quantiferon/Tspot (Attach Result) Date / / Result: Positive Negative INH Treatment (Attach) Date / / Provide name Medical Facility, address, phone number and fax number. (Stamp preferred)

7 Annual Tuberculosis (TB) Screening Questionnaire HEALTH SCIENCE STUDENTS 1. Do you have any of the following symptoms? (mark yes or no for each) Cough (especially if lasting for 3 weeks or longer) with or without sputum production Coughing up blood (hemoptysis) Chest pain Loss of appetite Unexplained weight loss Night sweats Fever 2. Have you had a BCG vaccine? 3. Have you ever had a positive PPD test or IGRA blood test? 4. Have you ever had close contact with persons known or suspected to Name: ID#: Major: have active TB disease? 5. List the country in which you were born. 6. List the countries in which you have spent more than two weeks in the past five years. 7. Have you been a resident, volunteer, and/or employee of high-risk congregate settings (e.g., correctional facilities, long-term care facilities, homeless shelters, medically underserved, low-income, or abusing drugs or alcohol)? 8. If any yes answers, please explain: Student Signature: Date: Reviewed by: Date:

8 Hepatitis B Vaccination and Titer Pathway Series of 3 vaccines administered at 0, 1, and 6 months. If you are mid series, continue with the series even if the time between vaccines is more than the recommended schedule. Do not start over. Titers may be ran 1 month after final vaccine in series. May need additional vaccines and titers based on titer results. History of vaccination: Quantitative Titer (blood draw) 1 month after Hepatitis B #3 vaccine was administered o If positive for immunity the process is complete o If negative or equivocal for immunity receive Hepatitis B #4 Repeat Quantitative Titer 1 month after Hepatitis B #4 was administered If positive for immunity the process is complete If negative or equivocal for immunity receive Hepatitis B #5, then 5 months later Hepatitis #6 If Hepatitis B #6 is necessary repeat Quantitative Titer 1 month after Hepatitis B #6 o If positive for immunity the process is complete o If negative for immunity please consult with your medical provider as a Hepatitis panel will need to be completed No history of vaccination: Hepatitis B #1: start immediately Hepatitis B #2: 1 month after #1 was administered Hepatitis B #3: 5 months after #2 was administered Quantitative Titer (blood draw) 1 month after Hepatitis B #3 vaccine was administered o If positive for immunity the process is complete o If negative or equivocal for immunity receive Hepatitis B #4 Repeat Quantitative Titer 1 month after Hepatitis B #4 was administered If positive for immunity the process is complete If negative or equivocal for immunity receive Hepatitis B #5, then 5 months later Hepatitis #6 If Hepatitis B #6 is necessary repeat Quantitative Titer 1 month after Hepatitis B #6 o If positive for immunity the process is complete o If negative for immunity please consult with your medical provider as a Hepatitis panel will need to be completed