Health Care Provider: Immunization
Health Care Provider: Immunization
Check List
□ A completed history and physical, that must be dated, signed and stamped by the student’s primary care provider, on our forms.
□ Tdap (tetanus/diphtheria/acellular pertussis) (Adacel), students must receive one dose of Tdap if two or more years have passed since the last Td booster dose or since the primary DPT series
□ 2 doses of the Measles vaccine, or a Rubeola IgG titer showing positive immunity results
If using LabCorp the test # is 096560 Quest Diagnostic test # is 52449W
□ 1 dose of the Mumps vaccine, or a Mumps IgG titer showing positive immunity results
If using LabCorp the test # is 096552 Quest Diagnostic test # is 64766R
□ 1 dose of the Rubella vaccine, or a Rubella IgG titer showing positive immunity results
(It is okay to have 2 doses of MMR to satisfy the above)
If using LabCorp the test # is 006197 Quest Diagnostic test # is 83626F
□ 2-step PPD * regardless of history of having received BCG
▪ Please include date placed and date read with mm (millimeters) of induration
▪ For a positive PPD, you must submit the date and size of induration, along with a current (within the past 12 months) chest x-ray report
□ 3 doses of Hepatitis B vaccine are required. If all 3 doses have previously been received, you must have a QUANTITATIVE Hepatitis B Surface Antibody titer showing immunity.
If using LabCorp the test # is 006395 Quest Diagnostic test # is 51938W
□ Hepatitis B Core Antibody and Hepatitis B Surface Antigen titers are required. This is to determine past or current infectivity.
If using LabCorp for HepBcAB Total test # is 006718 Quest Diagnostic test # is 51870E
If using LabCorp for HepBsAG test # is 006510 Quest Diagnostic test # is 265F
□ 2 doses of the Varicella vaccine or a Varicella IgG titer showing positive immunity results
If using LabCorp the test # is 096206 Quest Diagnostic test # is 54031E
* From MMWR: Guidelines for Preventing The Transmission of Mycobacterium Tuberculosis in Health-Cater Settings, 2005. Two-step testing is recommended for healthcare workers (HCWs) whose initial Tuberculin Skin Test (TST)(PPD) results are negative. If the first-step TST result is negative, the second-step TST should be administered 1- 3 weeks after the first TST result was read. If either 1) the baseline first-step TST result is positive or 2) the first-step TST result is negative but the second-step TST result is positive, TB disease should be excluded, and if it is excluded, then the HCW should be evaluated for treatment of latent TB infection (LTBI). If the first and second-step TST results are both negative, the person is classified as not infected with M. tuberculosis.
If the second test result of a two-step TST is not read within 48 – 72 hours, administer a TST as soon as possible (even if several months have elapsed) and ensure that the result if read within 48 -72 hours.
UMDNJ/Student Health & Wellness Center
90 Bergen Street
DOC Suite 1750
Newark, NJ 07103-2499
Phone: (973) 972-7687
Fax: (973) 972-0018
Student Health History
(To be completed by the student. Please print or type)
Name: _____________________________________________ School/ Grad Year: ___________________________________
(Last) (First) (MI) (NJMS, NJDS, GSBS, SHRP, SN, SPH, VISITING)
Date of Birth: _____/_____/_____ ( Male ( Female SS#: _____-_____-_____ If SHRP or SN:____________________
mo day year (Program)
Permanent Address___________________________________________________________________________________________
Street & Apt # City State Zip code
Contact Telephone(Cell): ___________________________ E-mail: __________________________________________
Emergency Contact: ___________________________________________________________________________________________
Name Relationship Telephone
Describe your usual health: (Excellent (Good (Fair (Poor
How often do you exercise a week? (Never (1-2 times (3-5 times (>5 times
How much tobacco do you use? (None (1 PPD (Other
How many alcoholic drinks do you have a week? (None (1-3/wk ( 4-6/wk (7+/wk
Do you have any ongoing health problems? (Yes (No If yes, specify diagnosis & date(s): ______________________
___________________________________________________________________________________________________________
Have you ever had surgery? (Yes (No If yes, specify procedure(s) and date(s): ________________________________
___________________________________________________________________________________________________________
Any hospitalizations not specified above? (Yes (No If yes, specify reasons(s) and date(s): ______________________
___________________________________________________________________________________________________________
Have you ever received treatment for anxiety, depression, eating disorders, alcohol or other substance abuse, or any other emotional/psychiatric problem? (Yes (No If yes, specify diagnosis and date(s): ______________________________
___________________________________________________________________________________________________________
Please specify any allergies to medications, latex, and other substances (include reaction). If none, write none: ___________
___________________________________________________________________________________________________________
Please list any medications you take regularly. Include all prescription medications, contraceptives, non-prescription medications, vitamins, herbs, supplements, and homeopathic remedies:_____________________________________________
___________________________________________________________________________________________________________
Has your activity been restricted in the past 5 years? (Yes (No If yes, specify reason(s) and date(s): _____________
___________________________________________________________________________________________________________
Name: ________________________________________ School/Year/Program: _____________________________
(Last) (First) (MI) (NJMS, NJDS, GSBS, SHRP, SPH, SN, VISITING)
Health History (continued)
Is there a family (parents, siblings, grandparents) history of:
Hypertension (Yes (No Who: ____________ High Cholesterol (Yes (No Who: _____________
Heart Disease (Yes (No Who: ____________ Stroke (Yes (No Who: _____________
Diabetes (Yes (No Who: ____________ Alcoholism (Yes (No Who: _____________
Cancer (Yes (No Who: ____________ Type: ______________________________________________
Psychiatric (Yes (No Who: ____________ Type: ______________________________________________
For women: Have you had a regular gynecological exam and Pap smear in the past year?* (Yes (No
*SHWC requires a gynecology exam (and Pap smear if indicated) within the past 12 months to obtain low-cost contraception at the Student Health & Wellness Center. We strongly encourage you to bring a copy of your most recent gynecology exam and Pap smear for your Student Health records.
I CERTIFY THAT THE ABOVE IS ACCURATE AND TRUE TO THE BEST OF MY KNOWLEDGE.
_________________________________________________________________________________________________________________________
Signature Date
________________________________________________________________________________________________________________________
Signature Date
PHYSICAL EXAM
( Must be completed by a physician, nurse practitioner, or physician’s assistant who is not a relative)
Physical Exam: (date of exam must be within 6 months of matriculation date)
Visual Acuity (with correction, if any): OD _______ OS _______ Correction? (Yes (No
Height (inches) ________ Weight (pounds) _________ BMI ________ BP _________ Pulse _________
Normal Abnormal Not Done If abnormal, please explain:
General appearance ( ( ( ________________________________________
Skin (scars, tatoos) ( ( ( ________________________________________
Head ( ( ( ________________________________________
Eyes ( ( ( ________________________________________
Ears, Nose, Throat ( ( ( ________________________________________
Neck ( ( ( ________________________________________
Lymph Nodes ( ( ( ________________________________________
Breasts ( ( ( ________________________________________
Heart ( ( ( ________________________________________
Lungs ( ( ( ________________________________________
Abdomen ( ( ( ________________________________________
Pelvic Exam ( ( ( ________________________________________
GU Exam ( ( ( ________________________________________
Spine ( ( ( ________________________________________
Extremities ( ( ( ________________________________________
Neurological Exam ( ( ( ________________________________________
Does this student require ongoing medical care? (Yes (No Specify: ______________________________________________________
_________________________________________________________________________________________________________________________
Date of Exam: _____/_____/_____ Clinician Signature: ________________________________________________________________
Clinician Name – Printed:_____________________________________________________________________________________________________
OfficeAddress:_____________________________________________________________________________________________________________
City: __________________________________ State: _______________ Zip Code: ________________ Country: __________________________
Office Telephone: ______________________________ ___________ Office Fax: __________________________________________________
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Contents of Student Health & Wellness Center student records may be disclosed to other persons or offices if considered necessary by the Service for the health or safety of any individual(s) or to consider the student’s ability to fulfill the Essential Functions of the educational program.
Any disclosure made to the Student Health & Wellness Center on this form or in any other manner does not constitute notice to UMDNJ of a disability or handicap and will not be considered a request for accommodations. All requests for reasonable accommodations must be made directly to the UMDNJ School in which the student is enrolled, in accordance with the procedures of the school.
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