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Student Medica Record

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Clara Nasr
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42 views1 page

Student Medica Record

Medical form

Uploaded by

Clara Nasr
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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Student Medical Record

Name: Date of Birth:


Mandatory Vaccines Date (MM/DD/YYYY) Instructions
Tetanus – Diphtheria Td: _ _/ _ _ / _ _ _ _ Tdap OR Td dose done within the last 10
(Td/Tdap) Tdap: _ _/ _ _ / _ _ _ _ years is required
MMR (Measles, Mumps, Dose 1: _ _/ _ _ / _ _ _ _ 2 doses of MMR vaccine are required
Rubella) Dose 2: _ _/ _ _ / _ _ _ _ OR
OR OR Date of measles, mumps and rubella
Measles titers Positive titers: _ _/ _ _ / _ _ _ _ positive titers with result of titers attached
Mumps titers Positive titers: _ _/ _ _ / _ _ _ _
Rubella titers Positive titers: _ _/ _ _ / _ _ _ _
Varicella vaccine Dose 1: _/ _ _ / _ _ _ _ 2 doses of Varicella vaccine are required
Dose 2: _ _/ _ _ / _ _ _ _ OR
OR
OR Date of positive titers with result of titers
Varicella titers Positive titers: _ _/ _ _ / _ _ _ _ attached
BCG: _ _/ _ _ / _ _ _ _ (if done earlier)
Tuberculosis Test OR TB QuantiFERON-
TST (aka: PPD) IGRA must be done within the last 12
Date placed: _ _/ _ _ / _ _ _ _ months
Date Read: _ _/ _ _ / _ _ _ _
Result: _ _ (induration in mm) If TST Induration > 10mm or TB
OR QuantiFERON-IGRA is positive. We require
TB QuantiFERON-IGRA date: _ _/ _ _ / _ _ _ _ a chest X-Ray with attached copy of the
Tuberculosis Screening Result: _ _ _ _ _ _ _ _ _ _ _ result.

Chest X-Ray: _ _/ _ _ / _ _ _ _ If positive TST or TB QuantiFERON-IGRA


Result: __ Normal __ Abnormal obtained earlier, provide date and result of
(if induration > 10mm) Chest X-Ray done.

Treatment Received (In case of positive TST) If treatment of Primary Tuberculosis


Date started: _ _/ _ _ / _ _ _ _ received, date and duration of treatment
Date ended: _ _/ _ _ / _ _ _ _ must be provided.
In case the student is going to stay at AUB
Meningococcal Vaccine Date: _ _/ _ _ / _ _ _ _ residency, a dose of Meningococcal
vaccine after age 16 is required
Hepatitis B Vaccine Dose 1: _ _/ _ _ / _ _ _ _ 3 doses of Hepatitis B vaccine are required
Dose 2: _ _/ _ _ / _ _ _ _ OR
OR Dose 3: _ _/ _ _ / _ _ _ _ Date of positive titers with result of titers
OR attached.
Anti HBs titers Positive titers: _ _/ _ _ / _ _ _ _

Optional Vaccines Date (MM/DD/YYYY)


Hepatitis A Dose 1: _ _/ _ _ / _ _ _ _
Dose 2: _ _/ _ _ / _ _ _ _
Human Papillomavirus Dose 1: _ _/ _ _ / _ _ _ _
Vaccine Dose 2: _ _/ _ _ / _ _ _ _
Dose 3: _ _/ _ _ / _ _ _ _

Physician’s Contact Information: Date of completing form: _____________________


Name: ____________________________ Phone Number: _____________________________
Signature: _________________________ Email: _____________________________________

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