Keiser University Health Forms. Student Name: D.O.B. / /

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1 These forms must be returned to Sentry MD. DO NOT RETURN THESE FORMS TO KEISER UNIVERSITY. Please return forms to Sentry MD, by ing them as ONE PDF ATTACHMENT to or fax to or These forms are to be submitted to Sentry MD by December 1, Part I Student Information: To be completed by student Name: (Please Print), MI Date of Birth: / / Keiser University Address Secondary Address Phone: ( ) - Emergency Contact, Relation Phone: ( ) - Please check as applicable: Year Transfer Full-time Part-time Additional Documents to submit: 1. Health Insurance: Students must submit a copy of your health insurance cards. Your health insurance cards must show a current date within a year and your name. If you are a dependent and not on the card or do not have a current date on them, you must provide additional documentation from your provider showing you as a current active member. 1

2 Part II Student Health History: To be completed by student Has anyone in your family ever had: Y=Yes N=No Please circle one 1. Stroke Y N 4. Tuberculosis Y N 7. Kidney Y N Disease 2. Cancer Y N 5. Diabetes Y N 8. Epilepsy, Y N convulsions 3. High Blood Pressure Y N 6. Heart Disease Y N 9. Mental Illness Y N Personal History To be filled out by student Have you ever had: Y=Yes N=No Please circle one 1. Had any kind of surgery? 2. Take any medications regularly? Y N 3. Had Chicken pox? Y N 4. Ever been hospitalized? Y N 5. Have any Y N chronic illness? Y N 6. Had measles? Y N If you answered YES to any of the above, please comment below. Current Medications List all current medications that you are taking. Allergies (Please list any known allergies environmental or to medications and reactions.) All statements on this questionnaire are true to my knowledge; I have no medical problems or health restrictions in this record. Student Signature Print Name: Date: / / 2

3 Part III Physical Exam: To be completed and signed/stamped by your Health Care Provider. This physical must be completed within a year of entry into Keiser University and must be kept current each year. Date of Physical Exam / / Height Weight BP Pulse Peak Flow Visual Acuity--Corrected R 20/ L 20/ Body System Normal Abnormal Findings Skin HEENT Thyroid Breasts Chest/Respiratory Heart Abdomen Musculoskeletal Genitourinary Reproductive Neurologic Psychologic Assessment: Include all current, ongoing, and significant past health problems (physical and mental/emotional). Do you have any reservations about this person performing the essential functions (physical capacity requirements) of a physician assistant? Yes No If yes, please explain: List any current medications and treatment recommendations: List any know allergies and reactions? Provider s Name PLACE PROVIDER S STAMP HERE Signature Phone ( ) 3

4 Part IV Immunizations: To be completed and signed/stamped by your Health Care Provider. Following recommendations by the CDC, to promote and maintain a safe environment at Keiser University and for you to participate in clinical practice settings, the following information is needed prior to enrollment. As some of these immunizations take up to 6 months to complete, please review this information carefully and begin any series that might require completion prior to a titer being drawn. Your health care provider (hcp) must complete and sign this form or include prior documentation of the required immunizations on a legitimate HCP form. All documentation must have a stamp or signature to be accepted. Measles, Mumps and Rubella (MMR): Proof of immunity by serology (Titer). Tetanus Diphtheria, Pertussis (TDAP): Within last ten years. Varicella: Proof of immunity by serology (Titer). History of disease is NOT acceptable; a positive titer result meets the requirement. Hepatitis B: Proof of immunity by serology (Titer). Meningococcal (Optional: Strongly recommended for students under 25 years of age. Students with immunodeficiency such as complement deficiency or asplenia should receive vaccine every 3-5 years. Tuberculosis Screening: (Required Annually) PPD (Mantoux) within the past 12 months (tine or monovac not acceptable). If PPD is positive, chest x-ray is required every five years. After submitting a normal chest x-ray at entry, an annual note from your health care provider that you are symptom free or a repeated normal chest x-ray will satisfy the yearly test required. Titer Dates: Measles (Rubeola): / / Mumps: / / Rubella: / / TDAP Date: / / Date of Titer: / / Immune Non-immune Hep B Surface Antibody Date: / / Quadrivalent polysaccharide vaccine: / / TB Skin Test Date: / / OR X-Ray Date: / / Results of MMR Titers Immune Non-immune Immune Non-immune Immune Non-immune Booster: / / Result of HepB Titer Immune Non-immune Result: Neg Pos Result: Neg Pos MMR Booster: / / HepB Booster Series: Dose 1: / / Dose 2: / / Dose 3: / / Influenza Vaccine: (Required Annually). Influenza Vaccine due by:11/1/15 Date: / / Drug Screening: (Required Annually). Attach Documentation of drug screening. Date: / / Provider s Name Signature Phone ( ) PLACE PROVIDER S STAMP HERE 4

5 Part V- Authorization of Release: to be completed by the student I have reviewed this immunization history for completeness and agree to release the information provided on the Keiser health forms to authorized members of Keiser staff and staff of cooperating agencies, as may be required. I understand that I may revoke or amend my authorization in writing at any time, but that I may not hold Sentry MD responsible for acting in reasonable reliance on this statement prior to the time they learn of my revocation or amendment. This authorization is valid during active student enrollment with Keiser University. Print student name: Date of Birth: Student Signature: Date: 5

6 1. Student information is complete in Part I. 2. Health History in Part II is complete. Keiser University-Student Checklist Physical Exam Part III is complete and signed by your Health Care Provider. 4. Immunizations in Part IV are complete with dates of titers/vaccines and results are signed by your Health Care Provider. 5. Release Statement Part V- signed by student. 6. Submit a copy of the following documentation: Health Insurance Drug Screen Documentation The above requirements are to be submitted to Sentry MD by December 1, Fax: & forms as one PDF attachment to: Any questions please Sentry MD at or visit our website at 6

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