St Christopher Iba Mar Diop College of Medicine
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1 St Christopher Iba Mar Diop College of Medicine Student Health History, Physical and Immunization Forms Please return all 3 parts of this form to: St Christopher Iba Mar Diop College of Medicine Department of Clinical Sciences 1200 Pennsylvania Avenue McDonough, GA If you have any questions please contact: The Department of Clinical Sciences Phone: (516) Fax: (516) ** PLEASE ATTACH A COPY OF PROOF OF PRIVATE HEALTH INSURANCE ** St Christopher Iba Mar Diop College of Medicine
2 HEALTH FORM TO THE STUDENT: The help form has three parts: Part I health history, Part II physical examination and Part III immunization record. All three must be submitted prior to registration in the college. It will be filed by the college for reference to be used whenever a consultation for illness or a conference for health appraisal takes place. This health form will also be sent to affiliated hospitals where students perform their clinical rotations in the U.S. The information in this health form is required by the college and its affiliated hospitals. Due to public health regulations, your history, physical examination and immunization records must be current and accurate in order for you to participate in clinical rotations at hospitals in the U.S. This material is also required for postgraduate training and when you join a hospital s medical staff as a fully licensed physician. You should keep a copy of all this material with updates at all times. You are to provide updates, additions and/or changes to the college as they occur or are required. Requirements for registration include completion, review and acceptance of the health form as follows: 1. Part I. Health history to be filled out by the student before seeing a physician for examination. 2. Part II. Physical examination to be filled out by a licensed physician. 3. Part III. Immunization record to be signed by a healthcare provider: a) Administration of a PPD test within one year. If the PPD test is positive, the results of a chest x-ray taken within one year, including date and place of examination must be submitted. BCG vaccination does not exclude a student from this requirement. b) Administration of tetanus or tetanus/diphtheria (Td) toxoid within the past ten years c) Proof of immunity against measles, mumps and rubella (MMR) requires either 1) a blood titter showing immunity to MMR or 2) two MMR vaccinations. d) The hepatitis B vaccination must be started and, if possible, completed prior to registration e) Proof of varicella immunity requires either a titter or a vaccination f) Hepatitis A vaccination is recommended g) Completion of a primary series of polio immunization is required.
3 PART I - HEALTH HISTORY Answer yes or no. If the answer to any question below is yes, provide names and addresses of all physicians or healthcare providers who participated in the diagnosis, referral or treatment. Give details, reasons, and dates as appropriate space below or additional pages, if necessary. A. Has your physical activity been restricted or your education interrupted for medical, surgical or psychiatric reasons during the past five years? B. Have you ever received treatment or counselling for a psychiatric condition, personality or character disorder or emotional problem? C. Have you ever had any illness or injury which required treatments by a physician, surgeon, psychiatrist or other healthcare worker? D. Have you ever been hospitalised for more than three days? E. Have you ever had a surgical operation? F. Please list any medications you are taking regularly G. Please list any allergies H. Do you have any condition which requires special consideration or treatment? I. Have you ever been denied medical or life insurance? If yes please give details Additional student/examining physician information
4 PART II - PHYSICAL EXAMINATION NAME: SOCIAL SECURITY# To the Examining physician: Please review the student's history and complete applicable parts of the examination form. Please comment on all positive answers using the bottom of page 3 or additional pages. Height weight blood pressure pulse vision Right 20/ Left 20/ corrected Right 20/ Left 20/ Describe any abnormalities of the following systems in the space below: Eyes ENT Neck Lungs Heart Breast Abdomen Rectum Nervous System Genitalia Extremities I have determined that is free from any health impairment which is of potential risk to patients or which might interfere with the performance of his/her duties. This includes the habituation or addiction to depressants, stimulants, narcotics, alcohol or other drugs or "substances" which may alter the individual's behaviour. Date: County of state license Signature: Physician's name Address Zip code
5 PART III - IMMUNIZATION RECORD Name: Date of birth social security no Permanent address To be completed and signed by a healthcare provider. All dates should include month and year. Include the manufacturers name and lot number whenever possible. A. TUBERCULOSIS SCREENING Date Manufacturer & lot # of the purified protein Derivative used in a standard mantoux "Intermediate PPD" (5 tuberculin units) Results in mm Signature of health care provider If the PPD is positive (equal to or > 10mm) a chest x-ray must be done immediately and yearly. Once a PPD is positive, a copy of the report must be sent to medical school services, Ltd immediately and yearly thereafter. In addition, a record of the chest x-ray must be noted at the end of this form under section "E". B. REQUIRED IMMUNIZATION Please see instructions on the front page. Check boxes where appropriate. Tetanus-diphtheria (TD) a. td booster within the last 10years Measles, mumps, rubella (MMR) a. 2 immunizations at least 30 days apart b. Positive serum antibody titter to MMR Hepatitis B a. 3 immunization at 0,1 month and 6 months Date Manufacturer & Lot# Signature of healthcare provider
6 IMMUNIZATION RECORD (CONTINUED) b,. Positive serum antibody titter results international units c. booster (if necessary) Polio a. complete primary series of polio immunization b. booster Live vaccine (OPV) Inactivated (IPV) C. RECOMMENDED IMMUNIZATIONS Hepatitis A a. 2 vaccinations at least 6 months b. positive serum antibody titter D. ADDITIONAL IMMUNIZATIONS: E. CHEST X-RAY For those students with a positive PPD, complete the following in addition to sending an official chest x-ray report to Medical School Services, Ltd. Date Result Radiologist
ST CHRISTOPHER IBA MAR DIOP COLLEGE OF MEDICINE
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Boston University Student Health Services 881 Commonwealth Ave 1 st floor WEST Boston, MA 02215 Phone: (617)-353-3575 IMMUNIZATION & PHYSICAL FM BU Student ID #: Necessary for all students U Instructions:
Immunisation Declaration Form - Version 2
All students undertaking an award within Institute of Health & Nursing Australia with a clinical/work experience placement component are required to ensure immunisations are up to date. Please read the