SACRED HEART UNIVERSITY HEALTH SERVICE - DOC

							                                                 Sacred Heart University
                                                     Health Services
                                                  Phone: 203-371-7838

Student Name _________________________________                                         Date of Birth _______

PART B Page 1 of 3 - DOCTOR: IMMUNIZATION HISTORY

DIPTHERIA/PERTUSSIS/TETANUS                          DPT (INITIAL SERIES) ____/____/____ ____/____/____ ____/____/____

TET, TDAP, DTAP TD, TD, DTaP/TD                      TETANUS BOOSTER (UPDATED WITHIN 10 YEARS TO DATE)
                                                      ____/____/____


POLIO SERIES                                         1ST ____/____/____ 2ND ____/____/____ 3RD ____/____/____


MMR #1 AND #2                                        DATE ____/____/____ (FIRST IMMUNIZATION AT OR AFTER 12 MONTHS
      OR                                             OF AGE AND IN OR AFTER 1969)
MEA ___/___/___ ___/___/___
Mumps ___/___/___ ____/____/___                      DATE ____/____/____ (SECOND IMMUNIZATION REQUIRED ON OR AFTER
Rubella ___/___/___ ____/____/___                    1/1/80)

Required by State of CT for Individuals born
after January 1, 1957

MENINGOCCOCAL VACCINE                                DATE ____/____/____ (REQUIRED FOR ALL STUDENTS RESIDING IN
(“MENINGITIS” VACCINE)                               CAMPUS HOUSING )


HEPATITIS B SERIES                                   1ST ____/____/____ 2ND ____/____/____
(highly recommended)                                 3RD ____/____/____


VARICELLA                                            NATURAL DISEASE ____/____ (MTH/YR)

Required by State of CT for Individuals born         VACCINE DATE #1____/____/____ #2_____/_____/____ OR
after January 1, 1980
                                                     TITER RESULT _________ DATE ___/____/____
                                                     Accompanied by the Laboratory Report


Tuberculin Skin Test Mandatory One Year Prior to Entering University: Multiple puncture tests such as Tine are not
accepted.
                                                          RESULT: (after 48-72 hours): _______mm induration
Date Planted:                  Date Read:                 If no induration, please put “0”
____/____/____                 ____/____/____
                                                          INTERPRETATION: ___ POSITIVE ____ NEGATIVE

                                                          Read by: ___________________________ (signature)


IF TB SKIN TEST POSITIVE-(CURRENTLY OR IN THE PAST) a chest x-RAY IS REQUIRED

Chest x-ray: ____ Normal ____Abnormal – please describe        Date of x-ray: ______
Treatment: No ____
              Yes ______________________________________________________
                      (Drug, dose, frequency, dates, location)




Doctor’s Stamp/Signature ____________________ Telephone No. _______________
                            SACRED HEART UNIVERSITY HEALTH SERVICES


    PART B Page 2 of 3 DOCTOR
    A Physical Examination Required Within one Year Prior to Enrollment at Sacred
    Heart University
    Student Name: ______________________________ Date of Birth: _______________
    Weight._____           Ht. _____     BP. ______ P________
    Vision: Right 20/_____ Left 20/ ____ With Glasses: Right 20/____ Left 20/ _____
    Hearing: Right ___________Left: ___________ Method used ___________________


   System         Normal               Describe if Abnormal     If Clinically indicated by history or
                                                                physical exam; required for Division 1
                                                                athletes only
    General                                                     Date:
  Appearance
      Skin                                                      Urinalysis

   HEENT                                                        SP.GR:

Neck, Thyroid                                                   Glucose:

 Chest, Breast                                                  Protein:

    Lungs                                                       Micro:

    Heart                                                       Date:

  Abdomen                                                       HGB/HCT

 Genitourinary                                                  Sickle Cell Status

Musculoskeletal
  Lymphatic

 Neurological

 Psychological




                                                                    DATE OF EXAMINATION
                                                                             ____/____/____


    8/8/2012
                              SACRED HEART UNIVERSITY HEALTH SERVICES


         PART B Page 3 of 3 DOCTOR
         Student Name: ______________________________ Date of Birth: _______________



List Current Medications Below                                            Allergies: ___ No known drug allergies.

                                                                          List Allergy & describe reaction
Name                       Dosage and dosing schedule
__________                 ______________________                         Medication Allergy________________________
__________                 ______________________                         Environmental/seasonal ____________________
__________                 ______________________                         Insect or Bee Allergy_______________________
__________                 ______________________                         Food Allergy _____________________________

EPI-PEN REQUIRED                   YES              NO     (PLEASE CIRCLE)
COMMENTS


         Special dietary requirements
         Comment _____________________________________________________________________
         Status of Student’s Physical Restrictions  Unrestricted  Partial Restriction  Full Restriction
         Comment ______________________________________________________________________


         Status of Student’s Health  Excellent  Good                  Poor
         Comment _______________________________________________________________________



PRINT: Health Provider’s Name _______________________________
Telephone # (       )_______-________     Fax # (     ) ________ - __________
Address ________________________________________ ________________ ________ __________________
           Street                                              City                State           Zip
Health Provider Signature__________________________________________ Date of examination____/___/___


                    ( This medical certificate will be on file in the University Student Health Center)



         8/8/2012