2008-2009 Health Statement for Visiting Students by jasonpeters

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									                         2009-2010 Health Statement for Visiting Students
             University of Hawai‘i, John A. Burns School of Medicine (UH-JABSOM)
            651 Ilalo Street, Honolulu, HI 96813-5534 Ph. (808) 692-1005 /Fax 692-1251
 PLEASE DO NOT PROVIDE INDIVIDUAL HEALTH RECORDS IN LIEU OF COMPLETING THIS
                                               FORM
      INCOMPLETE OR MISSING INFORMATION WILL CAUSE A DELAY OR NON-ACCEPTANCE OF
                                    APPLICATION
Student’s Name: ___________________________________ Date of Birth:________________________
Home School: _____________________________________
_______________________________________________________________________________________
Tuberculosis Control- current year PPD within 12 months preceding elective start date, and one result from the
previous year; or Two-Step Test within 3 months of elective start date (NOTE: if you were immunized with BCG > 5yrs ago,
a PPD is required!!)
PPD: Date placed (current year): __________________ Results _____________mm
      Date placed (previous year): _________________ Results _____________mm
OR: Date of Two-Step Test: Step 1 Date: __________ Results _____________mm
                               Step 2 Date: __________ Results _____________mm
OR, if PPD is positive:
Date of positive PPD:_____________ Result: __________mm
                  Date ____________ and result ____________ of subsequent Chest X-ray
    INH taken? ___Yes ___No If yes, inclusive dates? _______________________________________
          If other treatment, explain :________ ________________________________________________
Complete our “TB Symptom Questionnaire” (next page) if it is more than one year since your last Chest X-ray.
______________________________________________________________________________________T
etanus/Diphtheria (initial series, with latest booster taken within 10 yrs, preferably with Pertussis component (Tdap)
Dates #1: ________________ #2 _________________ #3: ________________
                         Date of Latest Booster (within 10 years of rotation end date): _______________
MMR Rubella, Rubeola and Mumps screening serology are required:
                         Date of (+) Rubella Titer: _________________
                         Date of (+) Rubeola Titer: _________________
                         Date of (+) Mumps Titer: _________________
For any Rubella, Rubeola or Mumps NEGATIVE/Equivocal results, TWO subsequent MMR doses are required:
                             Date #1: _______________ Date #2: ______________
_______________________________________________________________________________________
Polio (initial series of OPV or IPV; must include booster at age 4 or older):
Dates #1: ______________ #2 ________________ #3: _____________ AND Date of Booster: ___________
Varicella (titer required; history of disease is not acceptable):
                             Date of (+) titer: _____________________
Hepatitis B (series of 3 or serology):
                             Dates: #1 _______________#2________________ #3_______________
                            OR Date of (+) serology: ______________
Health Insurance
___Yes ___No This student is covered by personal or school health insurance during the entire elective period.
_______________________________________________________________________________________
Certification by Visiting Student’s Health Care Provider/School Official:
Printed Name: ______________________________________ Title: _______________________________
Signature __________________________________________ Date________________________________
Address:____________________________________________ E-mail:______________________________
 __________________________________________________ Phone:______________________________
                                                                                                               Rev. 04//08
                                                                  Name: ___________________________
                                                                  Date of Birth ______________________

                                   John A Burns School of Medicine
                                     TB Screening Questionnaire

               To be Completed ONLY by Students with a History of a Positive PPD Test
                              AND Chest X-ray Negative for active TB

All individuals who previously tested positive and were found to be free of active TB based on standard
chest x-ray and appropriate medical examination shall be screened for symptoms consistent with pulmonary
TB at the time of the Annual TB Re-evaluation.

PLEASE CIRCLE your responses below:

1. Have you had a cough lasting three weeks or more?     Yes      No

2. CIRCLE any of the following symptoms that you currently experience:

       Fever

       Night Sweats

       Unintentional weight loss > 10% of body weight

       Hemoptysis (blood in sputum)

       Malaise and/or fatigue


If you have answered YES to question # 1 AND have at least one of the Symptoms listed in question #2, a
standard Chest x-ray is required for TB clearance.




____________________________________                        ____________________
Student Signature                                           Date


____________________________________                       ____________________
Signature by UH-JABSOM Director of Student Affairs          Date

								
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