Immunization and Health Requirements 2017

Page 1 of 8

INSTRUCTIONS and FAQs pages 1-7; followed by FORMS pages 9-13

DUE DATES: PA Program – May 5, 2017; DO, DPM, DPT, MSA, & MBS Programs – June 23, 2017

Please submit the following documentation via mail, to the mailing address on page 4. If submitting a

lab test, an actual COPY of the LAB REPORT is required. LETTERS AND COPIES OF FLOWSHEETS ARE NOT

ACCEPTED AS A LAB REPORT. Documentation of immunization dates can include a copy of the

immunization record from your primary care provider or clinic; school records; state immunization

registries; military records. Below is a return checklist for your convenience.

DEMOGRAPHIC FORM

Demographic form – to be used to create an account in our electronic record system where your records will

be housed.

HISTORY & PHYSICAL EXAM

DMU’s History and Physical Exam form. A copy of a military physical is acceptable. Other forms will not be

accepted. Physical exams dated within 1 year prior to registration are acceptable. The history form needs to

be signed by the student. Make sure visual acuity is documented on the physical exam form.

MEASLES, MUMPS, AND RUBELLA—supporting documentation of the following:

2 MMR vaccination dates or positive IgG antibodies for measles, mumps, and rubella (lab tests)

**DO students: Many 4th year sites require titers for measles, mumps, and rubella. You will be

submitting these applications during your 3rd year. Some of those sites will want quantitative titers;

qualitative titers (results are noted as “reactive” or “positive”) are sometimes accepted IF they have a

reference range on the report defining what “reactive” means (e.g. “reactive: >= 1.90). If you get these

titers done now, be sure to submit a copy of the lab reports in addition to your vaccination dates.

Otherwise, please be mindful that you may need to get these lab tests later if you choose to apply to

one of these sites.

POLIO—supporting documentation of the following:

Primary vaccination dates for polio; if vaccinated and dates are not available, a recent IPV (Please do your

due diligence in tracking vaccination dates down now before getting an IPV. Call your undergrad facility, high

school, elementary, pediatrician, primary care provider, former healthcare employers, military, etc.)

DIPHTHERIA, PERTUSSIS, TETANUS—supporting documentation of the following:

Primary vaccination dates for DPT (Please do your due diligence in tracking vaccination dates down now.

Call your undergrad facility, high school, elementary, pediatrician, primary care provider, former healthcare

employers, military, etc.)

Tdap (1 dose)

Tdap OR Td within 10 years of anticipated DMU graduation date

Immunization and Health Requirements 2017, Lecture notes of History

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INSTRUCTIONS and FAQs pages 1-7; followed by FORMS pages 9-

DUE DATES : PA Program – May 5, 2017; DO, DPM, DPT, MSA, & MBS Programs – June 23, 2017

Please submit the following documentation via mail, to the mailing address on page 4. If submitting a

lab test, an actual COPY of the LAB REPORT is required. LETTERS AND COPIES OF FLOWSHEETS ARE NOT

ACCEPTED AS A LAB REPORT. Documentation of immunization dates can include a copy of the

immunization record from your primary care provider or clinic; school records; state immunization

registries; military records. Below is a return checklist for your convenience.

DEMOGRAPHIC FORM

HISTORY & PHYSICAL EXAM

AND

Additional note to DO students regarding other labwork and fourth year rotations: There are a couple of

TUBERCULOSIS

OR

Frequently Asked Questions

Name:___________________________ DOB:_________

Program: DO DPM PA DPT MSA MBS (circle)

MEDICAL HISTORY (to be completed by student)

Allergies : _________________________________________________________________________

Surgeries (procedure and year) : _________________________________________________________

________________________________________________________________________________

Chronic/serious illnesses/injuries (type of illness/injury and year) : ___________________________________

________________________________________________________________________________

________________________________________________________________________________

Current Medications (include dose and frequency) : _____________________________________________

________________________________________________________________________________

Y N Y N Y N

Please explain any “yes” answer :_________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

Patient Signature _______________________ Today’s Date ___________ Provider Review ____

Name:___________________________ DOB:_________

PHYSICAL EXAM

Date of Exam __________________ Sex: ___ Male ___ Female

REQUIRED : Vision Screen (Snellen) binocular__________ corrected or uncorrected (circle)

WNL

Detailed Description of ABNORMAL

findings

________________________________________________________________________________

________________________________________________________________________________

____________________________________ _____________________________________

____________________________________ _____________________________________

(____)_______________________________ _____________________________________

(____)_______________________________

FORM A, Page 2: Tuberculosis Risk Assessment Form

(Only complete if Step 1 or Step 2 test from page 1 is 5mm or greater)

Have you ever had close contact with anyone who was sick with TB? Yes No

Have you traveled to or lived in any of the countries below? If so, circle and indicate for how long. Yes No

Have you ever had an abnormal chest x-ray? Yes No

Do you have HIV or AIDS? Yes No

Are you an organ transplant recipient or donor? Yes No

Yes No

Yes No

gastrectomy, chronic malabsorption syndrome, low body weight (i.e. 10% or more below ideal)? ^ Yes^ ^ No

Yes No

Date Given:_______________ Date Read:______________ Induration:__________ Interpretation: Pos Neg

Signature of healthcare provider:_____________________________________ Date:________________

Printed Name:________________________________________ Phone #: ( )_____________________

Form A Page 2 of 2

FORM B: ANNUAL SIGN & SYMPTOM SURVEY

For all who have tested positive

Student Name:_______________________________________ DOB:________________

In accordance with CDC guidelines, DMU does not require periodic chest x-rays for those with a

previously positive TB skin test or IGRA (Quantiferon Gold or T-Spot tests). However, an annual

symptom survey is to be completed. Please answer the following:

In the past year, have you experienced any of the following symptoms NOT associated with a

specific illness (e.g. flu or cold) and lasting 3 weeks or longer?

Cough Yes No

Blood-Streaked Sputum (phlegm) Yes No

Unplanned Weight Loss Yes No

Night Sweats Yes No

Fever Yes No

Anorexia (loss of appetite) Yes No

_____________________________________________ ____________________

Student Signature Today’s Date

Form B: Page 1 of 1

Name:___________________ DOB:_

Patient Signature _________________ Today’s Date _ Provider Review

Name:___________________ DOB:_

Date of Exam ________________ Sex: _ Male ___ Female

_

_

()_ ___________

()___________________________

Date Given:___ Date Read: Induration: Interpretation: Pos Neg

Signature of healthcare provider:_____________________ Date:

Printed Name:____________________ Phone #: ( )_

Student Name:_______________________ DOB:

_________________________