M E HAR RY M E D I C A L C O L L E G E Student Health Services Dear Future Meharrian: Congratulations and Welcome to Meharry Medical College! Student Health Services at Meharry is dedicated to assisting you. We are here to help ensure your smooth transition into professional school and to provide support that will contribute to your academic and personal growth. The information presented below is very important and requires your immediate attention and response: IMMUNIZATIONS Prior to registration, all students entering Meharry Medical College must provide a HARD COPY of immunization record for measles, mumps, rubella, varicella (chicken pox), tetanus, diphtheria, pertussis, polio and Hepatitis B. A hard copy of the actual lab results of the quantitative Serologic titers must also be submitted. Documentation of the results of tuberculosis screening within the last 6 months (PPD) is also required. Student Health Services will review all documentation submitted to determine adequacy. Required Immunizations and Quantitative Serologic Titers: D: Hepatitis B vaccinations: documented series of 3 vaccines and Hepatitis B surface antibody quantitative serologic titer D: MMR (measles, mumps, & rubella): documented series of two doses and quantitative serologic titers D: Varicella: documented series of two doses and quantitative serologic titer or documented dated of disease and quantitative serologic titer. D: Tetanus/Diphtheria/Pertussis: documentation of TdaP vaccine within the last 5years. D: Polio: documentation of last immunization D: Tuberculosis Screening: within the last 6months: PPD or IGRA result or documentation of previous positive PPD, subsequent treatment and most recent chest x-ray report (within the last 6 months) Prior to registration, all students entering Meharry Medical College are required to have the Health Surveillance/Physical Examination forms completed by a health care provider. The physical exam should be performed within the last 3months. If you or your health care provider has questions, please email Student Health Service, shs@mmc.edu for assistance. All forms and records must be submitted to Student Health Services via email to shs@mmc.edu 1005 Dr. D. B. Todd Jr. Boulevard Nashville, Tennessee 37208-3599 T: 615.327.5757 F: 615.327.6027 www.mmc.edu
Student Health Services HEALTH SURVEILLANCE / PHYSICAL EXAMINATION 1. STUDENT'S INFORMATION Name: SSN: : of Birth: Age: Sex: ------- Program: Cell Phone Number: Home Phone: 2. HEALT H HISTORY ( STUDENT TO C OMPLE TE THIS SECTION) 0 0 Any illness or injury in the 0 0 High blood pressure 0 0 Loss of, or altered last 5 years? consciousness 0 0 Head/Brain injuries, 0 0 Muscular disease 0 0 Fainting dizziness disorders or illnesses 0 0 Seizures/epilepsy 0 0 Shortness of breath 0 0 Sleep disorders, pauses in 0 Medication breathing while asleep, daytime sleeping, loud snoring 0 0 Eye disorders or impaired 0 0 Lung disease, 0 0 Stroke or paralysis vision (except corrective emphysema, asthma, lenses) chronic bronchitis 0 0 Ear disorders, loss of 0 0 Kidney disease, dialysis 0 0 Missing or impaired hand, hearing or balance arm, foot, legs, finger, toe 0 0 Heart disease or heart 0 0 Liver disease 0 0 Spinal injury or disease attach; other cardiovascular condition 0 Medication 0 0 Digestive problems 0 0 Chronic low back pain 0 0 Heart surgery (valve 0 0 Regular, frequent alcohol 0 0 Narcotic or habit forming replacement/bypass, use drug use angioplasty, pacemaker) 0 0 Nervous or psychiatric 0 0 Diabetes or elevated disorders, e.g., severe blood sugar controlled by: depression 0 Diet 0 Medication 0 Pills 0 Insulin Medication For any YES answer, indicate onset date, diagnosis, treating physician's name and address, and any current limitation. List all medications (including over-the-counter medications) used regularly or recently. Student's Signature Page 1 of 4
Pages 2, 3 and 4 to be completed by the Health Care Provider Name: - 3. VISION Numerical readings must be provided. ACUITY UNCORRECTED CORRECTED HORIZONTAL FIELD OF VISION Right Eye 20/ 20/ Right Eye: Left Eye 20/ 20/ Left Eye: Both Eyes Color Vision D Normal D Abnormal Applicant meets visual acuity requirement only when wearing: D Corrective Lenses 4. HEARI NG A) Whisper Test Right Ear: /Feet Left Ear: /Feet B) Audiometer Test See attached reading 5. RATE Blood Pressure: Systolic: Diastolic: Pulse Rate: D Regular D Irregular Record Pulse Rate: 6. LABORATORY AND OTHER TEST FINDINGS URINE SPECIMEN SP.GR. PROTEIN BLOOD SUGAR 7. PHYSICAL EXAMINATION: Please Check Yes or No for each body system. Height: (in.) Weight: (lbs.) BMI: BODY SYSTEM CHECK FOR: 1. General Appearance 2. Eyes 3. Ears 4. Mouth and Throat 5. Heart Marked overweight, tremor, signs of alcoholism, problem drinking or drug abuse Pupils unequal, no reaction to light, impaired accommodation, impaired ocular motility, ocular muscle weakness, abnormal extraocular movements, nystagmus, exophthalmos. Ask about retinopathy, cataracts, aphakia, glaucoma, macular degeneration Scarring of tympanic membrane, occlusion of external canal, perforated eardrums Irremediable deformities likely to interfere with breathing or swallowing Murmurs, extra sounds, enlarged heart, pacemaker implantable defibrillator Page 2 of 4
Pages 2, 3 and 4 to be completed by the Health Care Provider Name: BODY SYSTEM CHECK FOR: Please Check Yes or No for each body system 6. Lungs and chest, not including breast examination 7. Abdomen and Viscera 8. Vascular System 9. Genito-urinary 10. Extremities 11.Spine, other musculoskeletal 12.Neurological COMMENTS: Abdominal chest wall expansion, abnormal respiratory rate, abnormal breath sounds including wheezes or alveolar rales, impaired respiratory function, cyanosis. Abnormal findings on physical exam may require further testing such as pulmonary tests and/or x-ray of chest. Enlarged liver, enlarged spleen, masses, bruits, hernia, significant abdominal wall muscle weakness Abnormal pulse and amplitude, carotid or arterial bruits, varicose veins Hernias Loss of impairment of leg, foot, toe, arm, hand, finger, perceptible limp, deformities, atrophy, weakness, paralysis, clubbing, edema, hypotonia. Insufficient grasp and pretension in upper limb to maintain grip. Insufficient mobility and strength in lower limbs Previous surgery, deformities, limitation of motion, tenderness. Impaired equilibrium, coordination of speech pattern; asymmetric deep tendon reflexes, sensory or positional abnormalities,. abnormal Patellar and Babinki's reflexes, ataxia 1. Does the student have any medical or psychiatr professional/graduate s c h o o l? D No D Yes If yes, please explain: ic diagnoses that may interfere with their matriculation in 2. Are you the student's primary care provider? I D No I D Yes Health Care Provider's Signature Page 3 of 4
Pages 2, 3 and 4 to be completed by the Health Care Provider Name: 8. IMMUNIZATION RECORD of Immunization MMR VACCINE #1 #2 MUMPS (Attach lab report) RUBEOLA (Attach lab report) RUBELLA (Attach lab report) VARICELLA Documented date of Disease or Immunization VARICELLA (Attach lab report) s of Immunization #1 HEPATITIS B # 2 #3 (Attach Lab report) TdaP POLIO PPD or IGRA (Attach lab report) Chest X-Ray (If Required, attach report) TB Chemoprophylaxis (If Applicable) of Last Immunization and Result and Result Start _ End Name and Dosage of Medication(s) _ Health Care Provider's Signature & : (MUST BE SIGNED TO BE VALID) Printed Name: Address : Page 4 of 4