Visiting Medical Student Health Information Form 2016-17

Student ID#: ______N/A______Quarter Attending: Fall / Winter / Spring / Summer Calendar Year: ______

PLEASE PRINT CLEARLY WHEN COMPLETING THIS FORM – ALL SECTIONS MUST BE COMPLETED

Student Identifying Information

Last Name: ______First Name: ______Middle Name: ______

Social Security #: ______xxx-xx-______Mother’s Maiden Name: ______

Date of Birth (mm/dd/yyyy): ______Sex: ______Marital Status: ______

Place of Birth: ______

Student Contact Information

Local Address: ______
(street address, apt #)

______

(city, state, zip code)

Local Phone Number: ______E-mail: ______

(area code + number)

Emergency Contact Information

Contact Name: ______Contact Phone Number: ______

(area code + number)

Relationship to Student: ______

Student Insurance Information

Insurance Company Name: ______

Insurance Company Address: ______

(street/PO box, city, state, zip code)

Insurance Policy ID: ______Group Number: ______Policy Holder’s Name: ______

Signature:______Date: ______

OFFICE USE ONLY

Reviewed by: ______Date: ______

Visiting Medical Student ImmunizationRecord 2016-17

Student ID#: ______Quarter Attending: Fall / Winter / Spring / Summer Calendar Year: ______

Part I: Student Information

Last Name: ______First Name: ______Middle Name: ______

Date of Birth (mm/dd/yyyy): ______Sex: ______Social Security #: ___***-**______

Preferred Telephone Number: ______E-mail: ______

Part II: Proof of Immunity

Part II is to be completed and signed by health care provider(s). A health care provider is a physician licensed to practice medicine in all of its pranches (MD or DO), a Licensed Nurse, or a Public Health Official.

MEASLES (Rubeola) / Date of blood titer: _____ / _____ / ______(mm/dd/yyyy)
Result: ______(must attach a copy of lab test in English)
RUBELLA (German Measles) / Date of blood titer: _____ / _____ / ______(mm/dd/yyyy)
Result: ______(must attach a copy of lab test in English)
MUMPS / Date of blood titer: _____ / _____ / ______(mm/dd/yyyy)
Result: ______(must attach a copy of lab test in English)
HEPATITIS B
(Both Step 1 and Step 2 are required.) / Step 1. Vaccine Series (must be started before entry to school)
Date of Vaccine # 1 _____ / _____ / ______(mm/dd/yyyy)
Date of Vaccine # 2 _____ / _____ / ______(mm/dd/yyyy)
Date of Vaccine # 3 _____ / _____ / ______(mm/dd/yyyy)
* Vaccine schedule as approved by the CDC: Three total doses given at 0, 1-2, and 4-6 months.
Step 2. Proof of Immunity (may be completed during first quarter of school)
Date of blood titer: _____ / _____ / ______(mm/dd/yyyy)
Result: ______(must attach a copy of lab test in English)
VARICELLA ZOSTER/ CHICKEN POX / Date of blood titer: _____ / _____ / ______(mm/dd/yyyy)
Result: ______(must attach a copy of lab test in English)
OR
Dates of immunization if you have not had chicken pox:
(Two doses separated by at least 30 days are required)
Date of Vaccine # 1 _____ / _____ / ______(mm/dd/yyyy)
Date of Vaccine # 2 _____ / _____ / ______(mm/dd/yyyy)
TETANUS/ DIPHTHERIA/ PERTUSSIS / A. To be completed for United States citizens / permanent residents ONLY.
Date of Vaccine _____ / _____ / ______(mm/dd/yyyy) Td or Tdap
(Date of vaccine must be within the last 10 years.)
B. To be completed for international students ONLY. You must provide three (3) documented doses of Td, the last dose given within the last 10 years.
Date of Vaccine # 1 _____ / _____ / ______(mm/dd/yyyy) Td or Tdap
Date of Vaccine # 2 _____ / _____ / ______(mm/dd/yyyy) Td or Tdap
(Date of vaccine must be at least 28 days after vaccine #1.)
Date of Vaccine # 3 _____ / _____ / ______(mm/dd/yyyy) Td or Tdap
(Date of vaccine must be at least 6 months after vaccine #2, and within last 10 years.)

Visiting Medical Student ImmunizationRecord 2016-17 (continued)

Student ID#: ______Quarter Attending: Fall / Winter / Spring / Summer Calendar Year: ______

Part III: Tuberculosis Screening

Tuberculin skin test (Mantoux only)
(to be completed within 3 months of entry) / Date of placement: _____ / _____ / ______(mm/dd/yyyy)
Date read: _____ / _____ / ______(mm/dd/yyyy)
Result: _____ mm induration (If no induration, record 0.)
OR
Chest X-ray, if the student has a history of a positive TB skin test or treated TB disease
(must be done in the USA within 1 year of registration) / Date of Chest X-ray: _____ / _____ / ______(mm/dd/yyyy)
(must attach chest X-ray report)
OR
Date of Quantiferon Gold/T-Spot test: _____ / _____ / ______(mm/dd/yyyy)
Result: ______(must attach a copy of lab test in English)

Part IV: Health Care Provider Certification

Provider(s) Signature:
Provider(s) Printed Name(s):
Address:
Phone Number:

OFFICE USE ONLY

Measles / G. Measles / Mumps / Tet/Dip / Hepatitis / Varicella
Immune
Exempt
Outstanding

Reviewed by: ______Date: ______