r'ir\ I TOURO COLLEGE ~ OF OSTEOPATHIC MEDICINE

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Where Knowledge and Values Meet

HEALTH HISTORY FORM TO BE COMPLETED BY STUDENT

TOURO COLLEGE OF OSTEOPATIDC MEDICINE 230 West 125th Street, New York, NY 10027 Telephone: 646-981-4500 Fax: 646-745-8704

Sex Date --------------------------------- -------- ---------------

Date of Birth ------------------------------ Social Security# ________________ _

Telephone -------------------------------Cell ________________________ __

Email

Emergency Contact N arne/Telephone-------------------------------------------

Past Health History (circle) Hypertension Cancer Hepatitis A-B-C Ulcers Asthma Bronchitis Arthritis Thyroid Anemia TB Diabetes 1-2 Kidney Disease Eczema Rheumatic Fever Heart Murmurs Severe Eyesight Disturbances Severe Allergies Hearing Problems Blood Clots Stroke Ulcers Sexually Transmitted Diseases (STD's) Depression Anxiety Suicidal Attempts Heart Disease Elevated Lipids Back Deformities Locomotion Challenges Deafness Blindness Herpes Speech Challenges Abnormal Pap Prostate Abnormalities Testicular Disease Mononucleosis

Surgical history----------------------------------------------------------

Hospitalizations (dates/cause/treatments)-----------------------------------------

Social History Smoker __ Years Alcohol __ Drugs_ Exposure to environmental toxins __ __

Current medications --------------------------------------------------------Allergies Drug Allergy (names) ---------------------------------------------­

Environmental/Latex -----------------------------------------

Family History Mother L D Health Status

Father L D Health Status Children L D Health Status Siblings L D Health Status

Symptom Review (circle) Fever Weight Gain/Loss Chills Sweats Loss of Appetite Nervous Tired Hair Loss Skin Rashes Sores Headache Blurred Vision Double Vision Ear Ringing Vertigo Trouble Hearing Frequent Nose Bleeds Sinus Troubles Bleeding Gums Frequent Strep Throat Neck Pains Chest Pains Shortness of Breath/Trouble Breathing Rapid Heart Beats Varicose Veins Scoliosis Kyphosis Wheezing Night Sweats Breast Lumps Breast Discharge Heartburn Rectal Bleeding Trouble Voiding Burning on Urination Testicular Masses Old Spinal Injuries Depression Anxiety Seizures

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Name

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PHYSICAL EXAMINATION FORM

TO BE COMPLETED BY HEALTH CARE PROVIDER

TOURO COLLEGE OF OSTEOPATHIC MEDICINE 230 West 125th Street, New York, NY 10027 Telephone: 646-981-4559 Fax: 646-745-8704

Sex ------------------------------------ -----------------------Height _____ _ Weight _____ _ B/P __ _ T _ _ _ P __ _ R ____ _

Vision Distance Uncorrected R 20/ L 20/ Corrected R/20/ L20/

Color Vision Normal Deficient -- --

Normal Abnormal Description of abnormalities (if any) Skin n a Eyes n a Ears n a Nose/Sinus n a Throat/Neck n a Chest/Thorax n a Heart n a Lungs n a Abdomen n a Extremities n a Osteopathic n a Structural Exam Neuro n a Psych/Mental n a Genito-Urinary n a

I have examined this potential Touro College of Osteopathic Medicine - NY student and found that he/she:

A. May participate fully in all activities involved without restriction. B. May participate with the following restrictions or accommodations. C. May not participate, due to issues of safety/other.

Health Care Provider: Name (Print): __________ ______ ___ _ Address: City, State: Telephone: Facsimile: E-Mail: Signature: Date:

CERTIFICATE OF IMMUNITY- Class of 2019

TOURO COLLEGE OF OSTEOPATHIC MEDICINE- NEW YORK 230 West 125th Street, New York, NY 10027

Telephone: 646-981-4559 Fax: 646-745-8704

Name Sex ___ _ Date of Birth _ _ ____ _

Social Security# ___ ___________ _ Email

Address

Telephone Cell Phone------------------ -

Please read and sign in the box below:

I authorize TOUROCOM-NY to release all immunization records to external rotation (clerkship) sites and/or to the New York Department of Public Health, or its designated representative, for compliance audits and in the event of a health or safety emergency or legally mandated reporting requirements.

Student Signature: -------------------- Date: ------------- - --

Required Titer Laboratory Reports - Give dates, serum lab values, and attach copies o{titers/lab reports

Positive Measles (Rubeola): Date Result

Positive Rubella (German Measles): Date Result

Positive Mumps IgG: Date Result

Positive Varicella (Chicken Pox) Titer IgG: Date Result

Hepatitis B Antigen: Date Result

Hepatitis B Antibody: Date Result

Hepatitis Core Antibody: Date Resu lt

Tetanus Booster (I within past I 0 years): Date

Recommended, but not required:

Hepatitis C Antibody Date: _____ _ Result: ______ _

Oral Polio or IPV Series (record doses) Dates:

#] _____ _ #2 _____ _ #3 _____ _ #4 _____ _

This student is free of communicable disease and is fit to work as a medical student in a hospital rotation Yes No

Examining Physician

Name _ _ _ _______ _____ _ Signature _______________ Date ______ _

TWO-STEP TUBERCULOSIS SCREENING- Class of 2019

Student Name (Print): -----------------------------

(A) STUDENTS WHO ARE NEGATIVE PPD REACTORS: Mantoux Testing must be done within 1 year of starting Touro College of Osteopathic Medicine - NY

Date Applied: _________ _ Date Read: ___ _______ _ Induration: ___ mm

(Complete line below only if 2-Step PPD is required by hospital)

Date Applied: _________ _ Date Read: ----------- Induration: ___ mm

(B) STUDENTS WHO ARE POSITIVE PPD REACTORS (LATENT Tb) OR CONVERTERS WITH PREVIOUSLY OR NEWLY POSITIVE SKIN TESTS, PLEASE COMPLETE SECTION B

First positive skin test date: ---------- -- Result (mm) ifknown: ------ - ---

BCG given in past: __ Yes __ No (lfyes, provide approximate date oflast BCG -------- - ---'

Date of Last CXR: Result: - -------- ---- (Attach Copy- Must be within 2 years.)

Dates of any treatment (INH prophylaxis for 6-9 months): - - ---- ------- --- ------

If no treatment and under 35 years old, why was treatment not given? ------- ------- ----

STUDENT REACTORS (LATENT Tb) OR CONVERTERS COMPLETE THE FOLLOWING SYMPTOM CHECKLIST:

Have you recently: Had an unexplained cough lasting more than 4 weeks? Had sputum production? Had an unexplained fever? Had unexplained weight loss? Had fever, night sweats or chills?

Yes ---Yes ---Yes ---Yes ---Yes ---

Student Signature: -------------------- Date:

No No No ---No No

Health Care Provider: 1 attest that all dates, immunizations and Tuberculosis screening results are correct and accurate.

Name (Print): Address: City, State: Telephone: Fax E-Mail: Signature: Date:

Send the completed forms (Certificate of immunity/Tuberculosis Screening, Health History/Physical Examination, and all other supporting documentation to:

TouroCOM Department of Clinical Education Touro College of Osteopathic Medicine, 230 W. 1251

h Street, New York, NY 10027 Telephone: 646-981-4559 Fax: 646-7 45-8704