Pre-Matriculation Physical Evaluation Form for Category A

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Pre-Matriculation Physical Evaluation Form for Category A January 1, 2017 Dear Doctor: Please complete the attached pre-matriculation physical evaluation and perform a physical examination for our incoming student. The following is a list of REQUIREMENTS that must accompany this form. A copy of the results for all titers must accompany the form. Please contact our office at 215-955-6835 if you have questions. Some frequently asked questions are addressed on website: http://hospitals.jefferson.edu/departments-and-services/ university-health-services/frequently-asked-questions/ Requirements: 1. Measles Immunity as documented by a positive IgG antibody titer (copy must be attached). a. If negative titer result for Measles, documentation of two MMR vaccines is needed (initial MMR series acceptable). 2. Mumps Immunity as documented by a positive IgG antibody titer (copy must be attached). a. If negative titer result for Mumps, documentation of two MMR vaccines is needed (initial MMR series acceptable). 3. Rubella Immunity as documented by a positive IgG antibody titer (copy must be attached). a. If negative titer result for Rubella, documentation of one MMR vaccine is needed (initial MMR series acceptable). 4. Varicella Immunity as documented by 2 Varicella vaccines OR positive IgG antibody titer (copy must be attached). 5. Tetanus/Diphtheria/Pertussis Immunity as documented by: a. A recent dose of the Tdap (tetanus/diphtheria/acellular pertussis) booster, recommended within 5 years of your start date. Common brand names are Adacel and Boostrix. Tetanus/Td will NOT be accepted. 6. Hepatitis B Immunity as documented by: a. 3 doses of the vaccine and a positive Quantitative Hepatitis B Surface Antibody b. If negative, receive 4th dose of the Hep B vaccine, repeat titer four weeks from the 4th dose. c. If repeat titer is positive, no further testing is needed. d. If repeat titer is negative, continue with doses 5 & 6 as scheduled. e. If Hep B Surface Antibody is negative after a secondary series (total of 6 doses), additional testing including Hep B Surface Antigen & Hep B Core Antibody should be performed. 7. Tuberculosis Screening a. IGRA Blood Test (Interferon Gamma Release Assay) is the required test, regardless of prior BCG status. To be performed within 3 months prior to the start of your first semester. Common brand names are Quantiferon-TB Gold and T-SPOT (copy of lab report must be attached). PPD will NOT be accepted b. If positive history along with INH treatment, a copy of a chest x-ray report done within the past 6 months is required. 8. Meningitis Vaccination a. Only students planning to reside in Jefferson housing must consider this vaccine. These students must provide the date of vaccination or provide the signed waiver form available on our website. 9. Seasonal influenza vaccine is mandatory during Flu season (Aug - April) a. Free flu vaccine will be provided by during the Fall semester b. If received outside of UHS, documentation is required. Include the following: date of vaccination, manufacturer, lot number, expiration date, signature of administrator. Sincerely, Ellen M. O Connor, MD, FACP Clinical Assistant Professor of Medicine Medical Director, Page 1 of 5

Last Name: First Name: : Sex: M F FtM MtF SS#: Campus Key: Current Address: City: State: Zip: Local Address: City: State: Zip: Home Telephone: ( ) Cell Phone Number: ( ) Jefferson E-mail Address: In case of an emergency contact - Name Previous Jefferson Student? (If yes, give program and year of graduation) No Yes @jefferson.edu Emergency Contact - Phone ( ) Current Jefferson Employee? No Yes Previous Jefferson Employee? No Yes Employment Termination : Previous visiting student or volunteer? No Yes If yes, date of visit or assignment: IF YOU DO NOT SEE YOUR PROGRAM LISTED, YOU HAVE THE WRONG FORM. you are entering (please include on all correspondence) COLLEGES/PROGRAMS/DEGREES College Biomedical Sciences Postbaccalaureate Pre-Professional (P4) Start Expected Graduation Sidney Kimmel Medical College VERIFICATION OF INFORMATION The following statements are true to the best of my knowledge. I understand that any false statement made purposely may be grounds for dismissal from the program. STATEMENT OF CONFIDENTIALITY All medical records within are confidential and will not be released without written authorization from the student. For infection control purposes, I give my permission to have ONLY my immunization and/or tuberculosis screening information forwarded for future participation in affiliate programs. This permission is in effect until I graduate from Jefferson or leave my program. I am aware that I may revoke this permission at any time. Signature Page 2 of 5

Medical History: Do you have, or have you ever had any of the problems listed below? (please check) Asthma Wheezing Chronic Cough Coughing of blood Shortness of breath Pneumonia Emphysema Tuberculosis High Blood pressure Rheumatic fever Heart murmur Heart attack Chest pain Angina Night Sweats Palpitations Leg swelling Phlebitis Kidney stones Blood in urine Urinary tract infection Difficulty with urination Sexually transmitted disease Syphilis Stroke Persistent dizziness Persistent headache Seizure disorder Loss of consciousness Paralysis Back trouble Pain down leg Numbness down leg Abdominal pain Hepatitis Jaundice Gall bladder disease Ulcer disease Blood in stool Vomiting blood Persistent diarrhea Anemia Bleeding Cancer Visual difficulty Hearing difficulty Skin rash Arthritis Gout Thyroid disease Diabetes Undue fatigue Excessive weight gain Excessive weight loss Depression Anxiety Eating Disorder ADHD Bipolar Disorder Do you have any medical problems not listed above? Y N Please list specific problems: Have you ever been hospitalized for any medical condition? Y N If yes: Month(s)/Year(s) Reasons Please list all surgical procedures: Procedure Do you take medications regularly? Y N If yes, please list (include vitamins, herbal supplements, birth control pills, etc.) Do you have allergies to medicine? Y N If yes, please list (include penicillin, sulfa drugs, tetracycline, etc.) and include reaction: Do you smoke? Y N If yes, how many cigarettes per day? If no, have you ever smoked? Do you drink alcohol? Y N If yes, amount: / day Do you have a sensitivity to latex? Y If yes, please explain workup: N Do you have a history of alcohol or substance abuse? Y N If yes, explain: Do you have any physical, medical, or emotional problems that you think may warrant special arrangements at school? Y N Do you have any medical complaints now? Y N Comments: Comments: Page 3 of 5

Student Immunization Documentation The following information is required prior to starting at Thomas Jefferson University. To be filled out by Physician, Nurse Practitioner or Physician Assistant MMR (Measles, Mumps, Rubella) Measles (Rubeola) Measles/Rubeola (IgG), antibodies, titer : POS NEG EQUIV Lab Report Attached Mumps Mumps (IgG), antibodies, titer : POS NEG EQUIV Lab Report Attached Rubella Rubella (IgG), antibodies, titer : POS NEG EQUIV Lab Report Attached Varicella (Chicken Pox) Dose #1 : Dose #2 : OR Varicella (IgG), antibodies, titer : POS NEG EQUIV Lab Report Attached Tetanus/Diphtheria/Pertussis (TDAP) - Recommended within 5 years of your start date. Vaccine : man/lot/exp: Hepatitis B Immunity - LAB REPORT MUST BE ATTACHED Dose #1 : Secondary Dose #4 : Primary Dose #2 : Hepatitis B Series Dose #5 : Hepatitis B Series (If no response to Dose #3 : primary series) Dose #6 : QUANTITATIVE Hep B Surface Antibody : QUANTITATIVE Hep B Surface Antibody : miu/ml Lab Report Attached miu/ml Lab Report Attached Hepatitis B Vaccine Non-responder (If Negative Hep B surface Hepatitis B Surface Antigen (If negative 2nd titer) : Lab Report Attached Antibody after Primary & Secondary Series Hepatitis B Core Antibody (If negative 2nd titer) : Lab Report Attached Chronic Active Hepatitis B Hepatitis B Surface Antigen : Lab Report Attached Hepatitis B Viral Load : Lab Report Attached Tuberculosis Screening - IGRA Blood Test (Interferon Gamma Release Assay) - LAB REPORT MUST BE ATTACHED To be performed within 3 months prior to the start of your first semester IGRA Blood Test (Interferon Gamma Release Assay : Lab Report Attached Positive History Only: Chest x-ray within 6 months required for all positive results Chest X-ray : Meningitis Vaccination - Only students planning to reside in Jefferson housing must consider this vaccine. Chest X-ray Report Attached Living in Jefferson Housing Yes No of vaccine (If answered yes) OR of declination Influenza - Vaccination is required for students during Flu season (Aug - April). Fall incoming students will receive in September. Vaccine : man/lot/exp: MD/CRNP/PA-C Signature Printed Name Phone # ( ) Address Page 4 of 5

Physical Examination BP / Pulse Ht ft. in. Wt lb Normal Abnormal Not Examined Remarks General Health Skin Ears EOMS Pupils Fundi Nose/Mouth Carotids Thyroid Lymph Nodes Lungs Heart Abdomen Extremities Cranial Nerves Motor Sensory Reflexes Visual Acuity (Snellen) Ishihara Vision: OD OS Color Blindness Screen: Normal Abnormal # plates of Corrected: OD OS of Last Eye Exam: To the best of my knowledge, based on my exam today, I believe this patient is: fit to be a student fit to be a student with the following restriction: not cleared MD/CRNP/PA-C Signature : Printed Name: Phone #: ( ) Address: Page 5 of 5

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