ࡱ> c \bjbj 4.ua\ua\eOv v >>>RRR8,,R:|~~~~~~$!$~>"mv8>||D&lpM!\h0d%%l%>%v > :  INCLUDEPICTURE "cid:image003.png@01CD7AE9.222AC790" \* MERGEFORMATINET  School of Medicine Health Form For Visiting Students Visiting students must use this form. To the Examining Practitioner: Please review the student's history and complete this examination form. This information is confidential. It will not be released to anyone without the student's knowledge and consent. Student Name _______________________________ Social Security ______ - _____ - ________ Student Birth Date ________________ (Will be used to verify immunizations when necessary) Name of Student's Home Institution _________________________________________________ Name of Examining Physician (Please print or type) ______________________________________ I examined the above named student on (Date) ___________________. The student is in good health and does not pose a health risk to patients or employees at the Hospital. Signature of Physician ________________________________ Date of Exam _________________ Examining Practitioner Address _______________________________________ Telephone No. (______) ______ - ______ Verification of Immunizations/Immunity Information: MMR: Titers (numerical values) are required in addition to vaccination dates. Rubeola (Measles) (Dates) _________________ _________________ Titer results ______________ (Date) ________ Positive _____ Negative________ Rubella (German Measles) (Dates) _______________ Titer results ______________ (Date) ________ Positive_____ Negative_______ Mumps (Dates) ________________ Titer results______________ (Date) ________ Positive_____ Negative_______ Varicella: Two (2) doses of vaccine, positive Titer is required Varicella Vaccine Dates ___________ ____________ Titer results______________ (Date) ________ Positive_____ Negative_______  INCLUDEPICTURE "cid:image003.png@01CD7AE9.222AC790" \* MERGEFORMATINET  School of Medicine Health Form For Visiting Students PPDMantoux: within 1 year mandatory (if test is positive, chest X-Ray is required) Date ____________ Positive ____ Negative _____ ______mm Chest X-Ray (if positive PPD attach report) Date __________ Place _______________________________ Result _______________________________ Tetanus: Booster or Td within 10 years (Date) ____________ Hepatitis B: vaccine (Dates) ________________ _______________ ________________ Titer results ______________ (Date) ________ Meningitis Vaccine I have had the meningococcal meningitis immunization (MenomuneTM ) within the past 10 years. Date received: ______________ *Meningitis Vaccine Declination: I read, or have had explained to me, the information regarding meningococcal meningitis disease. I understand the risks of not receiving the vaccine. I have decided that I will not obtain immunization against meningococcal meningitis disease. Signed ___________________________________________ Date ____________________ Influenza Date ________________ I have attached a photocopy of my health insurance card, which provides coverage while I rotate at University Hospital at Stony Brook. Student Signature ________________________________ Date___________  INCLUDEPICTURE "cid:image003.png@01CD7AE9.222AC790" \* MERGEFORMATINET  School of Medicine Health Form For Visiting Students Verification of Immunizations/Immunity Information by: Physician Signature ____________________________________ Date signed___________ Examining Practitioner Physician Name (Please print or type) ______________________________ Address ______________________________________________________ Zip ________ Telephone No. (Please include area code) __________________________     O:\\Acaaf\OME Administration\Forms\Visiting Student Forms\health 8-15-12.doc When completed, email directly to: Roseanna.Stasik@stonybrookmedicine.edu KNOafr - 6 C E = [ z " ; > ž}s}h_}Whq9lCJaJhq9l6CJ]hq9l6CJ]aJhq9l5>*CJ\ hkCJhq9l5>*\ hq9lCJ hq9lCJhq9lhq9l5CJ\ hq9lCJ hq9l5CJ hq9l5CJ, hq9lCJ( hq9lCJ&\#hB* CJOJQJ^JaJphI},jhB* CJOJQJU^JaJphI}!jhCJ&U\mHnHu Or 6 = C = > s ^TU^` &d P `> w y /8AB\]x T_`azbcdefľооx,j.hB* CJOJQJU^JaJphI}#hB* CJOJQJ^JaJphI},jhB* CJOJQJU^JaJphI} h@CJ hpWCJ hkCJ hOTCJ hq9lCJ *h}hq9lCJ *hpWCJ *h}hWI}CJ hWI}CJhq9l5CJ\-f46dt `` &d P &d P `gdpW ^fx}    23DEW9<45efvz{|}غششذإ؟؉؃ h@CJ hOCJ hrxCJhHohHo5CJ hHoCJ hq9lCJH*hq9lhHo hpWCJ hOTCJhO5CJ\ hkCJhq9l5CJ\ hq9lCJ hq9lCJ hq9l5CJ hq9l5CJ, hq9lCJ( hq9lCJ&\39-.{|}*rsu &d P gd@gdEgdk &d P  &d P gdO*3;\uv:EMrѿѨѿ~xrirr^rrrhO6CJ]aJhO5CJ\ hOCJ h@CJhEhkCJ hkCJ hk5CJ hk5CJ, hkCJ( hkCJ&\,jj]hB* CJOJQJU^JaJphI}#hB* CJOJQJ^JaJphI},jhB* CJOJQJU^JaJphI} hBCJ h0CJ hkCJ hq9lCJ$:b  gdYPgdOgdkgdO    .0VZ[\ӹ讧 hpWCJ hpW5\ hk5\hkhJhkB*CJphhJhXB*CJphhJhYPB*CJphheOh]khPjhPU hOCJ hkCJ"   0YZ[\gdOgdpW2P/ =!"T#$% Dp.Dd<  c AF ?îcid:image003.png@01CD7AE9.222AC790Description: Description: Description: Description: cid:image001.png@01CCE4A9.229D93A0b%-VZ`n60){-D,n,VZ`n60){PNG  IHDR2xsRGB,IDATx^t\յ5zUލ 6b^ !t/GH!ɂHHH0{,۲dIl63F˒ȇݥ9s9}>G"6v^K5jJ1YDRTyBD"H"Om&$pI f\&lu ڻlmݎ>ߠc0 Fynj5:׮WDG,<4=ި^CVJ bbgH\C~FS1[ [Wf]2H<;q5y߾7;Z~'y.q劶6i=v%%%"*f{[X)W%'*"&Ƅ.t HzatWSf;&?WjA^ԯ[c>1 Z⮍k}7enax#ş;A`$BفjXj<\giiƄE=*43 ]m?'յq渠e71L woULN[* ' Qߏ IT*/ŦJL|m$goDn6́L"EJ=g]=y|7h5!/n9 -$jaS&N[k.oX}RQ:Wڌ4[W'j2x2fyӽB>P|,7xB 3xG2hiʘ(GWsР+:]#5QS d%ʸK.0a0Ӝ_!ffa~HR|^ uIrXU#ժ" sLMƖEsq;~ 5! 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