SCHOOL OF MEDICINE HEALTH FORM FOR CLINICAL PLACEMENT
PART I - HEALTH HISTORY (Complete this part before going to your physician for an examination)
Name (Print) ________________________________________________________________
Last
First
Middle
Date of Birth __________________Social Security No.______________________________
Male ________ Female________ Home Telephone No._______________________________
E-Mail Address: _______________________________________________________________
Home Address________________________________________________________________
Number
Street
______________________________________________________________________________
City/Town
State/Country
Zip Code
Person to be notified in case of emergency:
______________________________________________________________________________
Name
Relationship
Home Telephone No. ___________________ Business Telephone No. ________________
Address______________________________________________________________________
Number
Street
_____________________________________________________________________________
City/Town
State/ Country
Zip Code
Please indicate if you have had any of the following in the past 12 months:
Yes
No
Yes
Cough
Sore Throats
Fevers
Skin Infections
Night Sweats
Rash
Weight Loss
Nausea
Shortness of Breath
Vomiting
Hemoptysis
Diarrhea
No
If yes to any of the above, please explain details and current status
___________________________________________________________________________________
____________________________________________________________________________________
PART I - HEALTH HISTORY (continued)
Name________________________________________________________________________
Last
First
Middle
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. Please
use additional 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 three years? Yes______
No ______ __________________________________________________
_______________________________________________________________________________________________________
B.
Do you have any physical disabilities or handicaps? _____________________________________________________
_______________________________________________________________________________________________________
C.
Have you ever received treatment or counseling for a psychiatric condition, personality, character disorder or
emotional problem?
Yes_______ No______
_________________________________________________________________________________
________________________________________________________________________________________________________
D. Have you had any illness or injury which required treatment or hospitalization by a physician or surgeon?
Yes______No______
___________________________________________________________________________________
________________________________________________________________________________________________________
E. List any medications you are taking regularly ____________________________________________________________
________________________________________________________________________________________________________
F.
Do you use drugs or substances that alter behavior? _____________________________________________________
________________________________________________________________________________________________________
G List any allergies and reaction ___________________________________________________________________________
________________________________________________________________________________________________________
H. Do you have any significant problems with your health at the present time? No _______ Yes_________________
_______________________________________________________________________________________________________
I declare that I have had no injury, illness or health condition other than specifically noted above
and will notify St. Georges University School of Medicine of any changes in my health status.
Date: _____________________
Signature: _________________________________________
PART II - PHYSICAL EXAMINATION
NAME_________________________________________________________________________________________________
Last
First
Middle
To the Examining Physician:
Please review the students Health History Form and complete applicable parts of the examination form. Please comment on all
positive answers using the back of this page or additional pages.
Height _____________Weight_______________ Blood Pressure ____________________ Pulse_____________________
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 that may alter
the individuals behavior.
________________________________
Date
__________________________________________
Signature of Examining Physician
Country or State License #____________________
___________________________________________
Physicians Name (Please Print)
Address: ____________________________________________________________________________________
City:_______________________State/Country:_________________________Zip Code:___________________
PART III - IMMUNIZATION RECORD
Name __________________________________________________________________________________________________
Last
First
Middle
Date of Birth ____________________________ Social Security No. _____________________________________________
Permanent Address _____________________________________________________________________________________
Number
Street
_______________________________________________________________________________________________________
City/Town
State/Country
Zip Code
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. Evidence of TWO tuberculosis screenings completed within the 90 days prior to expected clinical start date.
We accept the Mantoux skin test (PPD) or the QuantiFERON blood test. The PPD must be indicated in
millimeters. Students with a history of BCG vaccination or anti-tuberculosis therapy are not excluded from
this requirement.
1.
Intermediate PPD ( 5TU Mantoux Test)
Date: ______________ Product Name______________________Lot No: __________________
Result: ___________ mm. (Please indicate mm of induration)
PHYSICIAN/ REGISTERED NURSE SIGNATURE: ____________________________________
License #: _____________________________ State/Country: _____________________________
2.
Intermediate PPD ( 5TU Mantoux Test)
Date: ______________ Product Name_______________________ Lot No: __________________
Result: ____________ mm. (Please indicate mm of induration)
PHYSICIAN/ REGISTERED NURSE SIGNATURE: ____________________________________
License #: _____________________________ State/Country: _____________________________
If your QuantiFERON test or PPD is positive (> 10mm) now or by history, you need not repeat these. In this
case, the following statement must be signed and dated by a physician and submitted along with the official
report of a recent chest x-ray. The exam and the chest x-ray must be done within three months before your
expected clinical start date.
I have been asked to evaluate the above named student because of a positive PPD. Based on the students
history, my physical exam and recent chest X-ray (date ________), I certify that the student is free of active
tuberculosis and poses no risk to patients.
Physician Signature: _______________________________License#____________________ Date: ________________
Print Name: _________________________________________State/ Country_____________________________
PART III - IMMUNIZATION RECORD (continued)
NAME_______________________________________________________________________________
Last
First
Middle
B. OTHER MANDATORY REQUIREMENTS:
1.
Measles
Mumps
Rubella
Varicella
All students must submit copies of laboratory results of serum IgG antibody titers to measles, mumps,
rubella (MMR) and varicella. Immunization records are NOT accepted as proof of immunity. Any laboratory
results which indicate non-immunity require proof of additional vaccine administration.
2. Hepatitis B
Documentation of three doses of hepatitis B vaccine and followed by a positive hepatitis B surface antibody titer. Alternatively,
immunity may be documented by a positive hepatitis B core antibody. For training in the UK students must also submit have a
negative test for hepatitis B surface antigen (HBsAg).
Date
Hepatitis B
Three immunizations at
0, 1 month and 6 months
Manufacturer & Lot #
Signature of Healthcare Provider
1. ________
______________________
_____________________________
2. ________
______________________
_____________________________
3. ________
______________________
_____________________________
followed by a serum antibody titer. Students must submit a copy of a hepatitis B surface antibody test.
Booster (if serum
antibody titer is negative)
3.
Tdap (Adecel)
Booster within the last
5 years
Date
Manufacturer & Lot #
Signature of Healthcare Provider
________
_______________________
______________________________
Date
Manufacturer & Lot #
________
Signature of Healthcare Provider
_____________________ _______________________________
4. Meningococcal Meningitis Vaccine:
Information regarding this vaccine may be reviewed at www.cdc.gov/ncidod/dbmd/diseaseinfo.
Check one box and sign below:
[ ]
I have read the information regarding meningococcal meningitis disease. I will obtain the vaccine against
meningococcal meningitis within 30 days from my private health care provider.
[ ]
I have read the information regarding meningococcal meningitis disease. I understand the risks of not
receiving the vaccine. I have decided that I will not obtain immunization against meningococcal meningitis
disease.
[ ]
I have had the meningococcal meningitis immunization (Menomune TM) within the past 5 years.
received: ___________________
Student Signature____________________________________ Date__________________
PART III - IMMUNIZATION RECORD (continued)
5
Date
Name _____________________________________________________________________________________
Last
First
Middle
C. RECOMMENDED IMMUNIZATIONS:
1.
Polio
a. Completed primary series of polio immunizations
Dates: _________
____________
____________
___________________________
b. Inactivated polio vaccine (IPV) booster within the 10 years is required in the UK
2.
__________
_______________________
Date
Manufacturer & Lot #
Hepatitis A
a. Two vaccinations at least 6 months
apart.
or
b. Positive serum antibody titer
1)______
___________________
2)______
____________________
Date
_________
Lab Result
________________
________________________________
Signature of Healthcare Provider
_____________________________
_____________________________
Signature of Healthcare Provider
____________________________
D. ADDITIONAL REQUIREMENTS:
UK additional requirements:
1. Proof of a Polio IPV vaccine received within the past 10 years.
2. A lab copy of a Hepatitis b surface antigen test (negative result).
3. A lab copy of a Anti-HCV test (negative result).
Medical School -
09-2010
