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Medical Record Form Instructions

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Дария Коваленко
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26 views

Medical Record Form Instructions

Uploaded by

Дария Коваленко
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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DIRECTIONS FOR PREPARING AND RETURNING THE BUCKNELL STUDENT HEALTH MEDICAL RECORD

A. DEMOGRAPHICS PRINT CAREFULLY IN INK information requested. Also PRINT your name on PART IV.

B. PART I – MEDICAL HISTORY Ask your parents, guardian, or family physician to assist in completing this section.

C. PART II – MENINGITIS Meningitis (Meningococcal vaccine – A,C,Y, W-135): you must either check the box indicating you
have had the vaccine within the past three years and enter the date of the vaccine OR check the box indicating you have
declined the vaccine. The student’s signature (or parent/legal guardian’s signature if the student is under age 18) is
required no matter which box is checked.

D. PART III – CONSENT FOR TREATMENT SIGN and DATE (signature of parent/legal guardian necessary if student is under age
18).

E. PART IV – IMMUNIZATION RECORDS Complete (with the assistance of your physician, if necessary) all information
requested on the form. DO NOT enclose a separate immunization sheet.

REQUIRED IMMUNIZATIONS:

1) Tetanus/Diphtheria/Pertussis (TDAP) or Booster: A TDAP vaccine within the last ten (10) years is required. TDAP may
be administered regardless of interval since the last tetanus or diphtheria toxoid-containing vaccine.
2) Measles, Mumps, Rubella (MMR): Two (2) single doses of live measles (rubeola), mumps, and rubella vaccine or two
(2) combined doses of MMR vaccine at lease 28 days apart after 12 months of age and since 1981 are required. A
blood test showing immunity to measles, mumps and rubella will also be acceptable by providing lab reports. Having
had the diseases diagnosed is not sufficient.
3) Polio (OPV or IPV): Dates of basic series and last booster (administered at least one year following completion of basic
series).
4) Hepatitis B: A 3-shot series is required. The first of three (3) must have been given prior to enrollment at Bucknell.
The series must be completed within one (1) year. (There must be at least four (4) weeks between doses 1 and 2 and
at least eight (8) weeks between doses 2 and 3. Overall there must be at least four (4) months between doses 1 and 3.)
A blood test showing immunity will be acceptable by providing lab reports.
5) Chicken Pox (Varicella): Requirement is: history of having the disease; or two (2) doses of vaccine (the second dose at
least 12 weeks after first dose if administered between ages 1-12 years or at least 4 weeks after first dose if
administered at age 13 years or older); or blood test report showing immunity.
6) Mantoux Tuberculin Skin Test: The date and result of a Mantoux TB skin test done within one (1) year prior to your
first day of class at Bucknell regardless of previous BCG inoculation are required. If result is not shown, test is
considered invalid. A tine or monovac test is not acceptable. Result should be based on millimeters of induration and
Interpretation Guidelines shown on the BSH medical record form. If the test is positive, a chest x-ray must be done to
rule out active TB and an optional QFT-G, QFT-GIT, or T-Spot test may be done. If the chest x-ray, QFT-G, QFT-GIT, or T-
Spot is positive, proof of INH (Isoniazid) treatment is required. For a previous positive TB Test, record date and result
of test, date of chest x-ray and result, and treatment dates on the form.

F. PART V – PHYSICAL EXAMINATION Arrange for a physical examination (requirement is for a physical within one year prior
to your first day of class at Bucknell) and have PARTS IV and V completed and signed by the physician or medical service
after reviewing the immunization requirements listed above. PLEASE SHOW THIS INSTRUCTION SHEET TO YOUR
PHYSICIAN.

G. Return the entire completed medical form to Bucknell Student Health in the enclosed envelope not later than June 15 for
fall enrollment or January 3 for spring enrollment. You will not be able to complete your registration for your first
semester if your medical record is not received or is incomplete.

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