SGU Immunizations

8/12/2019 SGU Immunizations

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~ : c . . . . . .7 S \ N ( > ~ lYjj St George'sUniversity ~ / l ) I L ) ( : . ~ ~ / . S C H 0 0 L 0 F M E 0 I C I N E

THINK EYOND

August anuary df2 J May Year _MD MPH MSc Nursing Premedical Charter Foundation _

Part IA PERSON L INFORM TIONName Print) ~ 1 / ~ IDAOO _

ast / First MiddleDate of Birth Social Securi ty No. 8l T ~ ~ r ~Djt pff6

Male Female _Home Phone No. Cell Phone No. _ - - - L T . . . . : c ~ = _ _ _ _ _ + m ~ - - . . . L 7 1 - ~ - - < - r-----Home Address ~ / W ~ ~ S o U < o _ < _ v - I t ~ _ = . ; O c R . a - - n _ . . . . . . . . . . l o < T 2 _ _ _ c _ _ = _

Number Street

City/Town State Cou ntry Zip CodePerson to be notified in case of emergency:

tieYancleJc ~ d o r o . < - fNam RelationshipHome Phone No. Business Phone No. _

Cell Phone No. CJ f 6 3 ~ rCf JAddress UQ wdh Ikon lk tig -

Number StreetH a ~ - 2W 1CitylTown State Cou ntry Zip Code

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2/13

PartB HEALTH HISTORYName Print) ~ T l n J , . . . . . ~ ~ , , - , n ~ ~ Y - + - - - - 4 ~ - = - { . < < O , - - - - - _IJ; First MiddleAnswer Yes or No to all questions below. IF the answer to any question below is yes, provide names andaddresses of all physicians or health care providers who participated in the diagnosis, referral, or treatment. Givedetails, reasons, and dates as appropriate. Please use additional space below or additional pages, if necessary.A Has your physical actively been restricted or your education i n ~ p t e for medical, surgical, or psychiatricreasons during the past three years? YES NO

B Do you have any physical disabilities or handicaps? YES _ NO ~

C Have you ever received treatment or counseling for a p s y c ~ n d i t i o n personality or characterdisorder, or emotional problem? YES NO _

D. a v e ~ had any illness or injury which required treatment or hospitalization by a physician or surgeon?YES NO _

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3/13

Part IB HE LTH HISTORY continued)E List any medications you are taking regularly.

F Do you use drugs or substances that alter your behavior? YES _ NO _- -= --_

G. List any allergies and allergic reactions.

H Do you have any condition which requires special consideration or treatment? YES _ No L

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4/13

Part IB. HEALTH HISTORY (continued)Please indicate if you have had any of the following in the past 12 months:

YES NO YES NOough Sore Throat .-/

' --' /Fever Skin Infection...,/ight Sweats Rash,/'Weigh Loss Nausea

Shortness of Vomiting/Breath. -.:/- /Hemoptysis Diarrhea

If yes to any of the above, please explain details and current status:

I declare that I have had no injury, illness, or health condition other than specifically noted above and will notifySt. George s University School of Medicine of any changes to my health status.

Date: 1 ~ J L q b II _I S i g n a t u r e : ~ ~ ~ ~

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5/13

Part II PHYSIC L EX MIN TION

Name (Print) ~ a . : - I d s . ; . o t ~ ~ ~ ~ - - - - f . ~ . S O I / f L ' ' ' ' - ~ ___\ {J t / First MiddleTo the Examining Physician:Please review the student's Health History Form and complete applicable parts of the examination form. Pleasecomment on all positive answers using the back of this page or additional pages.

;;J r; 2Height .=10 W e i g h t r 0b ~ Blood Pressure - Pulse -Describe any abnormalities of the following systems in the space below:

Eyes cbENT (j)Neck

--- --dL-

Lungs sHeart r1BreastAbdomen v-~Rectum c DNervous System i PGenitalia

f\Extremities ~I have determined that ~ is free from any health impairmentwhich is of potential risk or which may interf r with the performance of his/her duties. This includes thehabituation or addiction to depressants, s nts, narcotics, alcohol , or other drugs or substances that mayalter the individual's behavior.

( IDate

Country or State License No. - C - _ - - - - - - - - _'CD.) fAce..

Physician's Name Please Print).;A 0 9::: ~ z =t 111 ex ~ 6 ~ddress

Number Street

N 0fl\1>I A Y 3 3 1 ~ DICity/Town State/Country Zip Code- 5


6/13

Part III T SCREENING ND IMMUNIZATION RECORD

Name (Print) - - - = 3 ' - ' C : ~ -.c::,{,c-:- _ 10 AOO _1a - o-- -S..LJ),(--.y_ -LKe..u ; " - ~ - ' - - -Last ( First Middle

Date of i r t h _ ~ u - - - l - l / W I _ _ ~ ~ / ~ 3 j - l { L 2 - - - - - - - Social Security No. O = . . . L ; - L 1 _ 7 L > . b < = - _ 3 - - l o . L 1 - = - 7 ~ _, IPermanentAddress ___/ ~ 1 ~ ~ ~ 0 ~ ~ S < ~ l ~ h 6 ~ ~ ~ u . ~ G e ~ { ~ t ~ / ~ \ __ ~ f r ~ S ~ L ~ ___Number Street

CitylTown State/Cou ntry Zip CodeTo be completed and signed by a health care provider All dates should include month and year. Include themanufacturer s name and lot number whenever possible.A MANDATORY TB SCREENING:To be completed and signed by a health care provider. All dates should include month and year. Include themanufacturer s name and lot number whenever possible, Please submit evidence of tuberculosis screeningcompleted within six months prior to registration. We accept the Mantoux skin test (PPD) or the QuantiFERONblood test. The PPD must be indicated in millimeters. Students with a history of BCG vaccination or antituberculosis therapy are not excluded from this requirement1. Intermediate PPD (STU Mantoux Test)

Date /;J ;2i ;;2011Result - - - - t - / ~ J - - - mm. (Please indicate mm of induration)PHYSICIAN / REGISTERED NURSE SIGNATURE _--+d1---1-__ ~ = : ; . . . _License No. - - N - - I C _ . : : : - t _ J _ l _ q _ ~ _ ~ _ \_ _tate/Country _----=---rw_ -'-I'J-r_=}:;J-=-(il..::...._--

If your QuantiFERON test or PPD is positive (> 10mm) now or by history, you need not repeat these. In thiscase, the following statement must be Signed and dated by a physician and submitted along with the officialreport of a recent chest x-ray. The exam and the chest x-ray must be done within three months prior toregistration date.I have been asked to evaluate the above named student because of a positive PPD. Based on the student's

history, my physical exam and recent chest X-ray (date , I certify that the student is free of activetuberculosis and poses no risk to patients.

PHYSICIAN / REGISTERED NURSE SIGNATURE _

Physician s / Registered Nurse Name (Please print) _

License No. Date State/Country _

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7/13

Part III - TB SCREENING AND IMMUNIZATION RECORD (continued)B. MANDATORY REQUIREMENTS1. Measles, Mumps, Rubella, Varicella:

All students must submit copies of laboratory results of serum IgG antibody titers to measles, mumps,rubella (MMR) and varicella. Immunization records are NOT accepted as proof of immunity. Any laboratoryresults which indicate non-immunity require proof of additional vaccine administration.

2. Tdap (Adecel) booster within the last 10 years:Date / / ,;It ..YO/ / Manufacturer and Lot No., 5 ~ / 1 6 / t?A.5br 4 t 39 ;)6(:4~ ,Signature of Health Care Provider ~ ~ . / t 11U0/7 I

3. Hepatitis BDocumentation of three doses of hepatitis B vaccine, and a positive hepatitis B surface antibody titer arenecessary. Alternatively, immunity may be documented by a positive hepatitis B core antibody. The hepatitisB vaccination is required for clinical training but is not required for registration at the University. If thehepatitis B vaccination has not been received prior to registration, it will need to be completed during thefirst two years of medical school. This must be followed with a serology for hepatitis B surface antibody.Hepatitis B Three immunizations at 0, 1 month, and 6 months:Date ________ Manufacturer and Lot No. _____________________

Date ________ Manufacturer and Lot No. _____________________Signature of Health Care Provider ___________________________

Date ________ Manufacturer and Lot No. _____________________

ANDSerum Antibody Titer (Copy of Lab Results must be submittedDate ________ Manufacturer and Lot No. _____________________

Booster (if necessary)Date ________ Manufacturer and Lot No. _____________________Signature of Health Care Provider ___________________________

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8/13

Part III - T SCREENING ND IMMUNIZATION RECORD continued)4.Meningococcal Meningitis Vaccine:

Information regarding thisvaccinemay be reviewedat www.cdc.gov/ncidod/dbmd/diseaseinfo Checkone box and signbelow:D havereadthe information regarding meningococcal meningitis disease.Iwillobtain the vaccineagainstmeningococcal meningitis within 30daysfrom my private health careprovider.

readthe information regarding meningococcal meningitis disease.Iunderstand the risksof not~ i v i n g the vaccine.Ihavedecided that Iwillnot obtain immunization againstmeningococcal

meningitis disease.D Ihavehadthe meningococcal meningitis immunization Menomune TM) within the past5years.Date Received Signatureof HealthCareProvider _

C. RECOMMENDED IMMUNIZATIONS1. Polio

a. Completed primary seriesof polio immunizations:Dates _

b.BoosterLiveVaccination(OPV)Date Manufacturer and LotNo. _Signatureof HealthCareProvider _Inactivated IPV)Date _ Manufacturer and LotNo. _

2.Hepatitis Aa. Twovaccinationsatleastsixmonths apart:

Date _ Manufacturer andLotNo. _Signatureof HealthCareProvider _Date _ Manufacturer and LotNo. _Signatureof HealthCareProvider _

b.Positiveserumantibody titer:Date _ Manufacturer andLotNo. _Signatureof HealthCareProvider _

- R-
http://www.cdc.gov/ncidod/dbmd/diseaseinfohttp://www.cdc.gov/ncidod/dbmd/diseaseinfo


9/13

Part III - T SCREENING ND IMMUNIZATION RECORD continued)ADDITIONAL IMMUNIZATIONS

Student ignature - / - : 1 ~ - = = - - . . L . . - ~ : z L - - = = - - ~ - - - - - - ate l q . . . . . . / ~ 1 ; - ; 6 = o ~ t I

SO 02 10


10/13

OCCUPATIONAL MEDICINE CENTERS OF AiYfERJCA..

VACCINE CONSENT FORiYf

DATE: p-/)CJ/IIrNAME /) NIA yJc 47SOCIAL SECURITY: 0-1 - V- - 312 7II UNDERSTAND THE RISK AND BENEFITS OF THISITHESE VACCINE(S) AND REQUEST THA TIT/THEY BE GIVEN TO ME.1 HAVE BEEN GIVEN THE INFORMATION PACKET(S) REGARDING THE VACCINE(S).

SIGNATURE: - - ; ? ; - - - : r : : . = - - - - - b - ~ . ~ 6 ~ - . DATE: 1:1- b6 It / ____ ' . . ,=>_. . . . . ~ ~ ~ 7 ~ ~ 1VACCINE MFG. LOT INJECTION SITE ADMINISTERED BYMMR#lMMR#2DIPHTHERlAJTETANUS .5C tlC r /;/1::;* ,( r2 /;Jc / / z ~ c /T' DCL? L/375C,C' /-J 6 Y F } 1 / .-L- Il J ~ j - f . . b . / . i J / / J u . . ~TETANUS TOXOIDHEPATITIS A#lHEPA TITIS A#2VARICELLA #1VARICELLA #2

IPOLIO

YELLOW FEVERPNEUMOVAX

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3705 Garfield Street Hollywood, FL 33021Ph 954-265-3406 Fcv.. # 954-265-2984 Email: [email protected]
mailto:[email protected]:[email protected]


11/13

ccupotk rdMedkIMCenters t I AmerkO3705 GoI fte d StrMtHollywood fL 33021QS4 265 3406

B L NCE DUEInvoice # : 10tInvoice Date: 121MD: Tech 1,

Claim#:Case#:DOI/DOA:Employer:

ChargeAmount Adjustment18,0030,0022,0035,0040,0065,00

210,00(210,00)0,00

OCCUPATIONiit MED tENi ER33','05 GARFIELD STREETHULLYJ.lOOO fL j3U21

R.f II uU01

SaleXXXXXXXXXXXX 68VISA tntr Method: SwipedTotal: 210.0(112 2Ml 10:29:04Inv n: 0@0001 Appr Code: 042910Apprvd: Online Batch : 000221

IHANK YIIII'

Credit Check CreditAmount Number Date(18,00) Visa#042910(30,00)(22,00)(35,00)(40,00)(6500)

BALANCE DUE: 0,00L_BalDuelnv 12202011

Patient Name: BOGDANSKY, KEVINPatient DOB: 05 13 1986Soc, Sec,#: 031-72-3729

Diagnosis:

Guarantor: Private Pay

ServiceDate: Procedures12 20 2011 TB test. PPD12 20 2011 Varicella titer12 20 2011 Rubella titer12 20 2011 Rubeola titer12 20 2011 Mumos Virus Antibodv12 20 2011 immunization- Tetanus/DiD/Pe

Code865808678785762867638673590721

TOTAL CHARGES:TOTAL OTHER PAYMENTS:TOTAL ADJUSTMENTS:


12/13

12 24 2011 Sat 12:11 EST. American Health Associates ID#53326

AMERICAN HEALTH ASSOCIATES15712 SW 41 Street , Suite 16 Davie, FL 33331954-919-5005ICLIENT ACCOUNT: 3308 I PATIENT: BOGDANSKY, KEVIN IACC#:22399098 IIOCCUPATIONAL MED CENTER IAGE: 25 GENDER: M ICOLL DATE TIME: I13705 GARFIELD ST IDOB: 05/l3/86 I 12/20/11 10:IHOLLYWOOD, FL 33021 IPT TD: IRCVD: 12/20/11 I1954-265-3406 ITEL: IRPTD: 12/24/11 II I I IIREQUESTING PHYS: IcHART - - - - - - - -- - -FAST ING : UN NowN II FLEIGELMAN, ROBERT M I I PAGE: 1 II I I =-------c==--=--I ~ P O R T STATUS: FINAL

RES U L T SI T ST - -- ~ rwITHIN R NGE l UT OF RANGE jREFERENCE R NGE IUNITSIs Var ice l la -zos te r Virus TgG Abs 2.45 (H) < 0.91 Index

REFERENCE RANGE for Var ice l la -zos te r IgG Abs:Less than 0.91 Index . . . . . Kegati ve0.91 - 1.09 Index ..... EquivocalGreater than 1.09 Index . . . Posi t i veA posi t ive resu l t indicates tha t the pat ien t has antibodyto VZV. I t does not d i f fe ren t i a t e between an active orinfcct ion. The cl in ical diagnosis must be in terpre ted inconjunction with the cl in ical signs and symptoms of thepatient .The presence of IgG VZV antibody IS consis tent withimmuni ty.

R Mumps IgG Antibodies 1. 63 H) < 0.91 IndexREFERENCE RANGE for Mumps IgG Abs:Less than 0.91 Index Negative0.91 - 1.09 Index EquivocalGreater than 1.09 Index posi t ive

s Measles IgG Antibodies 6.27(H) < 0.91 IndexREFERENCE RANGE for Measles (Rubeola) IgG Abs:Less than 0.91 Index . . Negative ~0.91 - 1.09 Index Equivocal ~ r:Greater than 1.09 Index posi t ive

s Rubella IgG Antibodies 44 (H) < 5 IU/mLREFERF.NCE RANGE for Rubella IgG Abc;:** Continued on Page 2 **

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13/13

1

12 2412011 Sat 1211 EST American Health Associates 10: #53326~ = : : . n eAMERICAN HEALTH ASSOCIATES deId IrHtHollywood. Iortda 33Q15712 SW 41 Street Suite 16 Davie, FL 33331 954 285 3406954-919-5005ICLIENT ACCOUNT: 3308 1 PATIENT: BOGDANSKY, KEVIN IACC#:22399098 1IOCCUPATIONAL MED CENTER IAGE: 25 GENDER: M 1 COLL DATE&TIME: 113705 GARFIELDIHOLLYWOOD, FL1954-765-l406

ST33021 1 DOB:1 PT ID:ITEL:05/13/86 1 12/20/11

1 RCVD: 12/20/11IRPTD: 12/24/1110:1I

I , 1 1 IIREQUESTING PHYS: ICHART: IFAST I NG: UNKNOWN 11 FLEIGELMAN, ROBERT M I IPAGE: 2 I

= 0=1 ~ ~ ~ ~ ~ IREPORT STATUS: FINALRES U L T S

TEST IWITHIN RANGEl OUT OF RANGE IREFERENCE RANGE IUNITS< 5 IU/mL NONREACTIVE: Anti.body level may beinsuff icent to provide protect ionagainst Rubella virus infect ion.

5 - 9 IU/mL INDETERMINATE: Repeat testing in 1-2weeks may help clar i fy Rubellaantibody status.> 9 IU/mL REACTIVE: Indicates current or pastinfect ion or vaccinat ion.(5) - es t Performed At: SPECIALTY Lru30RATORIES27027 TOURNEY ROADVALENCIA, CA 91355-5386

** End of Report ** DIRECTOR: JESUS E. VILORIA, M.D.

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SGU Immunizations