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Student Health RecordPOST-BACCALAUREATE MASTERS OF OCCUPATIONAL THERAPY DUE DATE: MAY 17, 2021POST-BACCALAUREATE DOCTOR OF OCCUPATIONAL THERAPY DUE DATE: AUGUST 1, 2021POST-BACCALAUREATE DOCTOR OF PHYSICAL THERAPY DUE DATE: AUGUST 13, 2021HEALTH RECORD SECTIONS TO BE COMPLETEDBY THE STUDENTHEALTH RECORD SECTIONS TO BE COMPLETEDBY HEALTH CARE PROVIDERPersonal Health History – OnlinePart 3 –Evaluation & Physical Exam (pages 3-5)Part 1 – Demographics (page 1)Part 4 – Immunization Record (page 6)Part 2 – Permission to Release Records (page 2)Part 5 – Surface Antibody Titers (page 7)Immunization Record – Online Submit your Student Health Record to the StudentHealth Portal at: usciences.studenthealthportal.com If you have questions or concerns, please contactStudent Health Services for guidance. Phone: 215-596-7133 or 215-596-8980Email: shac@usciences.edu

Student Health RecordPART 1 – DEMOGRAPHICSALL QUESTIONS ON THIS PAGE ARE REQUIRED. PLEASE ANSWER ALL QUESTIONS COMPLETELY.Legal Name of Student:Last NameFirst NameMiddle NamePreferred Name:USciences Student ID Number:Biological Sex:Major:Gender Identity: UndergraduateAcademic Level: Pharm DDate of Birth: OT PT Graduate PAMy Pronouns Are: Post-Baccalaureate Health Professional Other:Home Address in U.S.:Number and StreetCityStateZip CodeUniversity Student Housing: Off-campus/Commuter On-CampusOff-Campus Local Address:Number and StreetCityResidence Hall:State Learning Living Commons (LLC)Cell Phone Number: OsolZip Code WilsonEmail Address:Place of Birth:CityStateCountryIn case of emergency, contact:Name: Relationship: Telephone Number:Name: Relationship: Telephone Number:Rev. 5/11/2021DPT, MOT, DrOT Summer/Fall 2021 Student Health RecordPage 2

Last NameFirst NameStudent IDDate of BirthPART 2 – MEDICAL RECORDS RELEASETO BE COMPLETED BY STUDENTS ENTERING THE PHARMD, DPT, MOT, DOT, PA PROGRAMSPlease read and complete this form if you have been admitted to one of the following Health ProfessionalPrograms at the University of the Sciences (USciences): Pharmacy, Physical Therapy, Occupational Therapy, orPhysician Assistant.Your documentation must be submitted to the Fieldwork Experiential Management System and the StudentHealth Portal. However, if your department needs your original documents, the form gives us permission tosend them your Student Health Record documents.Health Professional Program (check one): Pharmacy Physical Therapy Occupational Therapy Physician AssistantBy signing below, I authorize the staff of USciences Student Health Services to provide a copy of the followingmedical records to my health professional program at the University, clinical training director, and experientialsite coordinator within the academic department indicated above:-Immunization RecordHepatitis B and Measles, Mumps and Rubella (MMR) Surface Antibody Titer Results (blood test results)Health Care Provider Evaluation & Physical ExamPlease Note: The information to be released will be limited to the specific items listed above. No furthermedical information regarding your medical history and/or your treatment history at Student Health Serviceswill be released to your academic program as a result of this release.SignatureStudent Name (printed)DateRev. 5/11/2021DPT, MOT, DrOT Summer/Fall 2021 Student Health RecordPage 3

Last NameFirst NameStudent IDDate of BirthPART 3 - HEALTH CARE PROVIDER EVALUATION & PHYSICAL EXAMTO BE COMPLETED BY A HEALTH CARE PROVIDERACCEPTABLE WITHIN ONE YEAR OF STARTING CLASSESNote to Health Care Providers Regarding Documentation Requirements Herein: The student who is requestingcompletion of these medical clearance forms has been admitted to a health sciences university that primarily educatesfuture Health Professionals. As such, the requirements regarding health evaluation, immunization, blood titers, andrelated documentation are a reflection of the rigorous standards imposed on students as a condition of matriculation inexperiential training at various medical centers, hospitals and other clinical sites. These requirements are reflective ofnational standards as published by the Centers for Disease Control and other public health-specific governing bodies, asdisseminated at the time this document went to press, and are therefore subject to change based on subsequentalterations in accepted practice in clinical medicine, epidemiology and public health. We appreciate your fullcooperation in completing this packet as it will ensure the student is not unfairly delayed in progressing through theirhealth professional training program due to failure to comply as requested.Date of Physical Exam: (acceptable within 1 year of starting classes)FULLY DESCRIBE ANY ABNORMAL FINDINGS IN THE FOLLOWING SYSTEMSNORMALHeadEyes & Fundoscopic ExamEarsNoseThroatNeckLymph NodesHeartLungsBreastsAbdomenHernia (male)MusculoskeletalPeripheral VascularNeurologic & Cranial NervesPsychiatric /Mental StatusSkinABNORMALDescribeSnellen : R /L /Screening Tests:HeightBlood PressureRev. 5/11/2021WeightPulse (resting)Body Mass IndexDPT, MOT, DrOT Summer/Fall 2021 Student Health RecordPage 4

Last NameFirst NameStudent IDDate of BirthTuberculosis (TB) Screening:Required: QTF-GIT or T-Spot Test: COPY OF REPORT REQUIREDDate: / /MO DAYYRResult: Negative Positive For those having had prior BCG vaccination, a QFT-GIT or T-SPOT .TB test (T-Spot) is therecommended method for TB infection screening (see Centers for Disease Control andPrevention guidelines). If you have had a prior positive Tuberculin Skin Test (PPD) or positive QTF-GIT or T-Spoto You need to meet with the Director of Student Health to determine the best course of actionfor annual TB Screening moving forward. Please call 215-596-8980 to schedule anappointment.o You will need to provide documentation of latest Chest X-ray results, and documentation ofdates of treatment and medication prescribed if treatment was received for Latent TB/TBExposure.Chest X-Ray: Required if GTF-GIT, T-Spot or PPD is Positive. COPY OF REPORT REQUIREDDate: / / Result: Negative Positive The Tuberculin Skin Test (PPD) is no longer recommended at Student Health. However if your healthinsurance does not cover the QFT-GIT or T-SPOT and requires you to have a Tuberculin Skin Test (PPD)please call SHAC at 215-596-7133 to speak with Maureen Hopkins, RMA who will guide you in thatprocess.Rev. 5/11/2021DPT, MOT, DrOT Summer/Fall 2021 Student Health RecordPage 5

Last NameFirst NameStudent IDDate of BirthSummary, Remarks and Recommendations:Is there loss or seriously impaired function of any organ? No Yes Explain:Is this student medically cleared to fully participate in collegiate or athletic activities? If not, please explain and notelimitations. No Yes Explain:Is the patient now under treatment for any medical or emotional condition(s)? No Yes Explain:If you answered yes to the previous question, do you have any specific recommendations regarding the care of thisstudent? No Yes Explain:Does this student have any communicable disease(s), Tuberculosis or other? No Yes Explain:Remarks or additional information:HEALTH CARE PROVIDER INFORMATIONName: Signature:Address: Phone Number:NPI Number: Date:STAMP OF HEALTH CARE PROVIDER’S OFFICE LOCATION:Rev. 5/11/2021DPT, MOT, DrOT Summer/Fall 2021 Student Health RecordPage 6

Last NameFirst NameStudent IDDate of BirthPART 4 - IMMUNIZATION RECORDTO BE COMPLETED BY A HEALTH CARE PROVIDER – ALL INFORMATION MUST BE IN ENGLISHWE DO NOT ACCEPT COPIES OF RECORDS FROM OTHER FACILITIES AS A SUBSTITUTE FOR COMPLETION OF THIS FORM.1. HEPATITIS B: Three doses of vaccine REQUIRED; AND Positive Hepatitis B Surface Antibody Titer (IgG)Required if series completed2. POLIO: Primary series REQUIRED. Three primary series areacceptable.3. TETANUS-DIPHTHERIA-PERTUSSIS: Primary series of DTap, DTP, DT or Td REQUIRED;Last Td required to be within the last 10 years AND One dose of Tdap (tetanus toxoid, reduced diphtheriatoxoid and acellular pertussis) vaccine REQUIREDHEPATITIS B SERIESMO/DAY/YRMO/DAY/YRMO/DAY/YRHEPATITIS B REPEAT SERIESMO/DAY/YRMO/DAY/YRMO/DAY/YRPOLIO: IPV /YRMO/DAY/YRMO/DAY/YR**Last Td vaccine required to be in the past 10 yearsTDAP4. VARICELLA (CHICKEN POX):History of Disease is Not Sufficient If you have had a documented case of Chicken Poxdisease, one of the following is REQUIRED:o Positive Varicella Antibody Titer (IgG); ORo Two doses of Varicella vaccine If you have not had Chicken Pox disease or have anegative antibody titer, two Varicella vaccines areREQUIRED.5. MEASLES, MUMPS, RUBELLA (MMR): Two doses of vaccine REQUIRED; AND Positive MMR Antibody Titer (IgG) REQUIRED6. MENINGOCOCCAL: ALL Healthcare Professional Clinical Students andstudents residing in University housing are REQUIRED toobtain the Meningococcal Conjugate Vaccine (MCV) orMeningococcal Polysaccharide Vaccine (MPSV) aftertheir 16th birthday, regardless of prior vaccinationhistory. Additional vaccination against meningitis serogroup Bremains optional. Discuss vaccination criteria with yourHealth Care Provider.7. HUMAN PAPILLOMAVIRUS RecommendedVARICELLAMO/DAY/YRMO/DAY/YRVARICELLA ANTIBODY TITER (IgG)MO/DAY/YRUPLOAD OFFICAL LAB RESULTS TOSTUDENT HEALTH PORTALMEASLES, MUMPS, RUBELLA (MMR)MO/DAY/YRMO/DAY/YRBOOSTER MO/DAY/YRMENINGOCOCCAL*REQUIRED* MCV MPSVMO/DAY/YR MCV MPSVMO/DAY/YR**If first vaccine was given before age 16, a second vaccine after the 16th birthday isREQUIRED.MENINGOCOCCAL SEROGROUP BMO/DAY/YR*OPTIONAL/RECOMMENDED*MO/DAY/YRHUMAN PAPILLOMAVIRUSMO/DAY/YRHealth Care Provider SignatureRev. 5/11/2021MO/DAY/YR:MO/DAY/YRMO/DAY/YR HPV4 HPV9MO/DAY/YRDateDPT, MOT, DrOT Summer/Fall 2021 Student Health RecordPage 7

Last NameFirst Name8. COVID-19 Vaccine RequiredStudent IDDate of BirthBrand: Moderna ; Pfizer ; Johnson and Johnson ; OtherVaccine #1 - MO/DAY/YRVaccine #2 - MO/DAY/YRPART 5 - SURFACE ANTIBODY TITERSTO BE COMPLETED BY A HEALTH CARE PROVIDERHEPATITIS B, MEASLES, MUMPS & RUBELLA SURFACE ANTIBODY TITERS ARE REQUIRED OF ALL STUDENTS.Hepatitis B Surface Antibody Titer (IgG)Titer Test Date: / /MO DAY YRTiter Test Results: ** PROVIDE STUDENT WITH OFFICIAL LAB RESULTS **In the event that the Hepatitis B titer is “nonreactive” or shows “equivocal” immunity: The student is REQUIRED to repeat a Full Second Hepatitis B series, and obtain a repeat titer 4 to 6weeks after the last vaccine.Students with a negative surface antibody titer must upload initial titer results and documentation of abooster vaccine by the deadline in order to avoid a late fee. If you are completing a second Hepatitis B immunization series, you must upload documentation aftereach vaccine in order to avoid a Health Hold.Measles, Mumps, and Rubella (MMR) Surface Antibody Titers (IgG)Titer Test Date: / /MO DAY YRTiter Test Results: ** PROVIDE STUDENT WITH OFFICIAL LAB RESULTS **In the event that any part of the MMR titer is “negative” or shows “equivocal” immunity, the student isREQUIRED to receive a booster vaccine, and obtain a repeat titer 4-6 weeks later.Students with a negative surface antibody titer(s) must upload initial titer results and documentation of abooster vaccine by the deadline in order to avoid a late fee.Health Care Provider SignatureRev. 5/11/2021DateDPT, MOT, DrOT Summer/Fall 2020 Student Health RecordPage 8