Health Immunization Form - WebCampus - Drexel University ...

Office of Student Immunization Surveillance
Drexel University College of Medicine
2900 Queen Lane – Room 102
Philadelphia, PA 19129
imm_surv@drexelmed.edu
Phone (215) 991-8560 // Fax (215) 843-0214
June 2010
Dear First Year Medical Students,
Welcome to Drexel University College of Medicine!
Below is a list of Health-related requirements. All forms, including the required lab studies, must be
completed and returned to the Office of Immunization Surveillance no later than July 16 th 2010. Please
use the Immunization Status Checklist as a guide, incomplete forms will not be accepted.
Pre-Placement Medical Evaluation Form:
The Pre-Placement Medical Evaluation Form contains a Basic Health Questionnaire. Please complete the
first page (down to the signature on page 1). Page 2 is for the actual physical exam.
Required Immunizations
Full Health Policy available at: http://webcampus.drexelmed.edu/handbook/HealthPolicy.html
Tuberculin Testing
Prior to matriculation (entering first year of medical school), all Students must complete Two-Step
Tuberculin Skin Testtesting (PPD). . The first step must be completed within 12 months of the second
step. The second step must be completed within two months of matriculation to medical school (After
June 1, 2010). If you have received BCG Vaccine, you are still required to have a Two-Step Tuberculin
Skin Test. If you have documentation of a positive PPD, you must provide records indicating treatment
rendered and additionally, the results of a chest x-ray taken within one year of matriculation to medical
school.
Hepatitis B
All medical students are required to have been immunized against Hepatitis B. Hepatitis B immunization
consists of a series of three injections that should be completed prior to matriculation. Students who do
not have documentation of the dates of the series of three vaccines, may instead submit written proof of
positive immunity.
Measles/Mumps/Rubella
All students are required to have two Measles/Mumps/Rubella (MMR) immunizations. Students without
documentation of two specific dates of their MMR immunizations must submit written proof of positive
Antibody Titers for Measles, Mumps and Rubella.
Polio, Tetanus, Diphtheria, Pertussis
Students are required to have documentation of their primary series against Polio. Students are required to
have documentation of their primary series in Diptheria/Pertussis and Tetanus. Additionally, students
shall have had a Tdap booster within the past ten years. Students with a DT booster greater than two years
ago are still required to have a Tdap booster.
continued on next page

Varicella
Students with a history of varicella must have it documented. Appropriate documentation includes a date
of Varicella infection (Chicken Pox), in writing, from a healthcare provider. Students without a history of
varicella, or vaccination, must submit written documentation of positive Antibody titer. Non-immune
students will not be permitted on clinical services.
Recommended Immunizations
Meningococcal
Meningococcal vaccine is recommended prior to matriculating to medical school.
Hepatitis A
Hepatitis A vaccine is recommended prior to matriculating to medical school.
Physical Examination:
You must have a physical examination prior to enrolling in medical school. Your health care provider
must utilize the Pre-placement Medical Evaluation Form to document his/her findings. If you have any
questions please contact the Office of Student Immunization Surveillance at (215) 991-8560 or
imm_surv@drexelmed.edu.
NOTE: All students matriculating to Drexel University College of Medicine are required to have
the above components completed prior to arriving for Orientation in August 2010 or the Dean’s
Office will be notified and you may be asked to leave classes until the required documentation is
completed.
Sincerely,
Erin Clark
imm_surv@drexelmed.edu
Office of Student Immunization Surveillance
Drexel University College of Medicine
2900 Queen Lane – Room 102
Philadelphia, PA 19129
Phone (215) 991-8560 // Fax (215) 843-0214

Drexel University College of Medicine
Pre-Matriculation Medical History/Physical Exam Form
Demographics:
Name:________________________________________
Date of Birth: _____/_____/_____
Family History:
Has anyone in your immediate family had any of the following:
Date Form Completed:____________
Age:____________
Please circle yes or no.
Heart Disease Yes No Diabetes Yes No
High Blood Pressure Yes No Cancer Yes No
Stroke Yes No Tuberculosis Yes No
Sudden Death (before 50) Yes No Asthma Yes No
Epilepsy Yes No Gout Yes No
Migraine Headaches Yes No Marfan’s Syndrome Yes No
Eating Disorder Yes No Sickle Cell Yes No
Personal History:
1. Have you ever been hospitalized? Yes No
Have you ever had surgery? Yes No
Are you presently under a doctor’s care? Yes No
Please give dates and any details for questions answered yes.
2. Please list any medications you are currently taking and for what conditions.
3. Please list any known allergies.
4. Have you ever had a head injury/concussion? Yes No
Have you ever been knocked unconscious? Yes No
Have you ever had a seizure or epilepsy? Yes No
Do have recurring headaches or migraines? Yes No
Please give dates and details for questions answered yes.
I hereby state that, to the best of my knowledge, my answers to the above questions are correct.
Student Signature
Date Signed

Physical Examination To be completed by Healthcare Provider
 Male
Month Day Year
Name Date of Birth Gender
 Female
Height:____________________ Weight:_____________ Blood Pressure________________ Pulse:_____________
Visual Acuity: OD_______ OS_______ OU_______  Corrected
Yes / No
Hearing:  Intact  Abnormal – explain:_____________________________________________________
Laboratory
tests:
Urinalysis:
Hemoglobin:
 Within Normal
Limits
 Within Normal
Limits
 Abnormal –
explain:_________________________________________
 Abnormal –
explain:_________________________________________
Clinical Evaluation
1. Skin
2. Head, Ears, Eyes, Nose, Throat
3. Mouth, Teeth, Gums
4. Neck and Thyroid
5. Lungs/Chest
6. Breasts
7. Heart (supine and standing)
8. Abdomen
9. Genitalia
10. Back/Spine
11. Extremities/Musculoskeletal/Femoral Pulses
12. Neurologic
13. Emotional/Psychological
14. Other findings
Normal Abnormal Comments
Loss of paired organ function:  Yes  No If yes, please explain: _______________
_____________________________________________________________________________________________
This student is able to meet the physical and emotional demands of medical school:  Yes  No
If no, please explain_____________________________________________________________________________
_____________________________________________________________________________________________
I have examined this student and attest the above information is accurate and complete to the best of my knowledge.
Signature of Health Care Provider
Date
Print Name of Health Care Provider Phone Fax
Address
*** Do no write below this line ***_______________________________________________________________________________
Missing Information
 Letter sent
initial____ date_____
Physical and Immunization  Completed: initial____ date_____
 Immunizations__________________________________________________________________
 Physical Examination_____________________________________________________________

Drexel University College of Medicine
Student Immunization and Surveillance Office, Room 102
2900 W. Queen Lane, Philadelphia, PA 19129-1029
imm_surv@drexelmed.edu
215-991-8560 telephone /// 215-843-0214
Immunization Records – To be completed and signed by healthcare provider. Page 1 of 2
Last First Middle Month
(MM)
Day
(DD)
Year
(YYYY)
NAME OF STUDENT
Date of Birth
REQUIRED IMMUNIZATIONS
*Copies of positive serology reports must be submitted in lieu of dates of immunization.
Diptheria/Pertussis/Tetanus*
Primary Series and a Tdap
administered within the last
ten years
1 st Dose 2 nd Dose 3 rd Dose 4 th Dose 5 th Dose Tdap
Polio*
Primary series of OPV, IPV or
sequential IPV-OPV
Measles/Mumps/Rubella*
(MMR)
1 st Dose 2 nd Dose 3 rd Dose 4 th Dose 5 th Dose
1 st Dose 2 nd Dose
Varicella*
Date of documented
Disease by Healthcare
Provider.
Month
(MM)
Day
(DD)
Year
(YYYY)
OR
Date of 2 doses in
varicella series.
1 st Dose 2 nd Dose
Hepatitis B Vaccine*
1 st Dose 2 nd Dose 3 rd Dose
*Copies of positive serology reports must be submitted in lieu of dates of immunization.
2-Step PPD Tuberculin Skin Test:
(Mantoux) 2 ND Step Must be Within
TwoMonths of Matriculation
(Second Step after June 1, 2010)
1 st PPD Tuberculin Skin Test
Date given
Date read
Results
(Record actual mm of induration, transverse diameter: if no
induration write “0”) Interpretation (base on mm of induration
as well as risk factors)
Results
Negative OR
Positive. If
Positive continue
with required
Chest X-ray below
2 nd PPD Tuberculin Skin Test-
Chest X-Ray required if
tuberculin skin test is positive.
Copy of x-ray must also be
attached.
Result
Date of
Chest
X-ray
Specify treatment if Positive PPD
Date treatment
started
Date treatment
completed
continue on next page

Immunization Records – To be completed and signed by healthcare provider. Page 2 of 2
continued
Last First Middle
Month
NAME OF STUDENT
(MM)
Day
(DD)
Year
(YYYY)
Date of Birth
RECOMMENDED IMMUNIZATIONS
Meningococcal Vaccine
One dose required
Menomune
OR
Menactra
Hepatitis A
Two doses required.
1 st Dose 2 nd Dose
Signature of Health Care Provider
Date
Type/Print Name
Email
Address
Telephone & Fax
Revised 05/27/10
Drexel University College of Medicine
Student Immunization and Surveillance Office, Room 102
2900 W. Queen Lane, Philadelphia, PA 19129-1029
imm_surv@drexelmed.edu
215-991-8560 telephone /// 215-843-0214

Drexel University College of Medicine
Office of Student Immunization Surveillance
2900 Queen Lane – Room 102
Philadelphia, PA 19129
imm_surv@drexelmed.edu
Phone (215) 991-8560 // Fax (215) 843-0214
Immunization Status Checklist for Students
(Do Not Return This Form)
All students at Drexel University College of Medicine must provide the Office of Student Immunization Surveillance with
proof of immunity to certain diseases.
Below are the required immunizations along with acceptable documentation.
Please read each section carefully as any documentation submitted incorrectly will cause a delay in beginning classes.
Immunization Requirement Documentation DONE
POLIO Proof of immunization (primary series). Written documentation of
immunizations signed by a
healthcare provider
TETANUS-
DIPHTHERIA and
PERTUSSIS
(Tdap)
Proof of immunization (primary series)
and booster within the last 10 years.
Written documentation of
immunizations signed by the
healthcare provider.
MMR
(MEASLES, MUMPS,
RUBELLA)
VARICELLA
(CHICKEN POX)
TUBERCULOSIS
HEPATITIS B
Proof of immunization (TWO DOSES
of MMR Vaccine) or proof of adequate
antibody titer.
Proof of immunization (TWO DOSES
of VARICELLA Vaccine) or proof of
adequate antibody titer.
Proof of two negative Tuberculin Skin
Tests (PPD). The first step must be
completed within 12 months of the
second step. The second step must be
completed within two months of
matriculation to medical school
(After June 1, 2010). If Positive
Tuberculin Skin Test (PPD), Proof of
prior treatment AND Negative CXR
within the last year.
Proof of immunization (THREE
DOSES of HEPATITIS B Vaccine) or
proof of adequate antibody titer.
Written documentation of the
dates of immunizations signed
by the healthcare provider or a
copy of the laboratory report
documenting the titer.
Written documentation of the
dates of immunizations signed
by the healthcare provider or a
copy of the laboratory report
documenting the titer.
Written documentation by a
healthcare provider documenting
negative Tuberculin Skin Tests
(PPD).
If positive Tuberculin Skin Test
(PPD), written documentation of
treatment and dates AND negative
CXR with in the past year.
Written documentation of the
dates of immunizations signed
by the health care provider or a
copy of the laboratory report
documenting the titer.

Office of Student Immunization Surveillance
Drexel University College of Medicine
2900 Queen Lane – Room 102
Philadelphia, PA 19129
imm_surv@drexelmed.edu
Phone (215) 991-8560 // Fax (215) 843-0214
Any questions should be directed to Erin Clark, imm_surv@drexelmed.edu, 215-991-8560.
Health and immunization and other documentation records are maintained for current
medical students as part of the academic record necessary for rotation placement. Documents
are destroyed following graduation. We recommend that you maintain a copy of your
health/immunization record with both your personal physician and with your own personal
records.
As we will suggest with all of your records, we strongly recommend that you retain a copy of
documents for your personal records prior to forwarding a copy to the medical school. Records
should be forwarded to the address below.
Office of Student Immunization Surveillance
Drexel University College of Medicine
2900 Queen Lane – Room 102
Philadelphia, PA 19129
Phone (215) 991-8560 // Fax (215) 843-0214
Revised May 28, 2010