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