Plea complete and return by January 15, 2011 to Student Health Services at the campus
where you are enrolled. For more information:
Student Health Services Queens and Manhattan campus
8000 Utopia Parkway
Queens, NY 11439
Tel (718) 990-6360
Fax (718) 990-2368
www.stjohns.edu Height: ______________ Weight: ____________ Blood Pressure: _________ Pul: _________Vision: ________ Right: _______ Left: _______ Corrected: Right: ________ Left: ___________
For Allied Health Professional Students only: Color Vision Screening Normal _____________ Abnormal ______________
Hearing:Urinalysis Result: _____________________________________________________ Date: __________Blood Count HCT: ___________________________ HGB: __________________ Date: __________
韩文网名Normal Abnormal Normal Abnormal Head, neck, face and scalp ______ _______ Abdomen ________ _________No and sinus ______ _______ Endocrine System ________ _________Mouth, teeth, gingival ______ _______ Extremities ________ _________Ears ______ _______ Reflexes ________ _________Eyes ______ _______ Musculoskeletal ________ _________Lungs, chest and breasts ______ _______ Lymphatic ________ _________Heart ______ _______ Neurologic ________ _________
Vascular ______ _______Check one Tetanus-Diphtheria booster (within the last 10 years) Date:________ DTaP Date: _________Tuberculin Skin Test (within six months of date of this exam)Mantoux: Result: _________________mm induration. Date: _______________________________
IF TUBERCULIN SKIN TEST IS POSITIVE: Chest x-ray required. Date: _____________ Result: ___________________________________________________________Polio ries completed: Yes No
Varicella vaccine Do 1 Date: _______ Do 2 Date:________ Dia Date: ___________________
Hepatitis B vaccine (recommended) Do 1 Date: ______ Do 2 Date: ______ Do 3 Date: _______
Meningococcal vaccine (recommended for students living in the residence halls) Date: ___________Family history (relevant health problems): _________________________________________________
In your judgment, is there any reason why physical activities would be contraindicated? Yes No
If yes, explain: ________________________________________________________________________
(Plea u name stamp or attach RX with your signature)
Physician’s Name (Print): ______________________ Date of Exam: ___________________________
Registration Number: __________________________________________________________________
Address: _____________________________________________________________________________
Tel: ________________________________________ Signature: _______________________________
Physical Examination
Staten Island campus Campus Center 300 Howard Avenue Staten Island, NY 10301Tel (718) 390-4447Fax (718) 390-4480笔记本分辨率
(To be completed by Physician or Health Care Provider.)
Plea complete and return by January 15, 2011, to Student Health Services
at the campus where you are enrolled.
Office of Health Services Queens and Manhattan Campus
乒乓球直板8000 Utopia Parkway
Queens, NY 11439
Tel (718) 990-6360
Fax (718) 990-2368
www.stjohns.edu Name: ________________________________________ Date of Birth: ______________________________________Address: ___________________________________________________________________________________________Student ID #: __________________________________ School/Campus: ____________________________________The New York State Legislature pasd Public Health Law 2165 in June 1989, requiring ALL students attending colleges and universities in New York State who were born on or after January 1, 1957, to be immunized against measles, mumps and rubella. Documentation of immunization must be completed before class begin. Students who fail to prent adequate documentation will not be permitted to register.
Proof of immunization consists of one of the following:
1. A certificate of immunization signed by your physician or health care provider (e form below).
2. A student health record from a previously attended school that properly documents your immunization history.
3. Serologic testing for MMR antibodies with laboratory copy of same is acceptable proof of immunity.
4. Documentation that proves you have attended primary or condary school in the United States AFTER 1980 will be sufficient proof that you have received one do of live measles virus vaccine. You must also provide a
certificate of immunization that documents a do of measles vaccine was administered within one year prior to attendance at the post-condary institution. Documentation of mumps and rubella vaccines as stated above must also be provided.
For physician to complete:
1. This student has received MMR immunization: (It is required by law that students receive TWO dos of measles vaccine and ONE do of mumps and rubella vaccine. An immunization given bef
ore 1968 is acceptable only if the immunization record specifies that the vaccine was a live virus vaccine.) A do of live virus measles, mumps and rubella vaccine must be administered no more than four days prior to a child’s first birthday, and a cond do of live measles, mumps and rubella vaccine must be administered no less than 28 days after the first do.
MMR
(first do date): ______________________ (cond do date): ________________________Measles
(first do date): ______________________ (cond do date): _______________________Mumps
(first do date): ______________________ (cond do date): ________________________Rubella (first do date): ______________________ (cond do date): ________________________
2. Serologic evidence of immunity for MMR: (Plea attach laboratory reports.)
Physician’s Signature: _____________________________________________________________滋润保湿
___________________Address: ___________________________________________________________________________________________Licen #: _____________________________________ Phone: ____________________________________________Immunization
(Plea retain a copy for your files.)
Staten Island Campus Campus Center 300 Howard Avenue Staten Island, NY 10301Tel (718) 390-4447Fax (718) 390-4480
Important Meningitis Information
St. John’s University is in compliance with New York State Public Health Law 2167, which requires ALL students attending colleges and universities in New York State to be given information relating to immunization against meningococcal meningitis. By law you must respond to this notification within 30 days.
An airborne dia, meningococcal meningitis is transmitted through droplets of respiratory cretions and from direct contact with persons infected with the dia. College students spending
many hours together in clo physical contact and/or living in confined areas such as residence halls are at an incread risk of contracting the dia. Meningococcal meningitis caus an inflammation of the membranes covering the brain and spinal cord. It can be treated with antibiotics but is sometimes not diagnod early enough. Symptoms of the most common type of meningococcal meningitis are high fever, vere headache, stiff neck, naua and vomiting, lethargy and a rapidly progressing rash. The dia strikes about 3,000 Americans and claims about 300 lives each year. Between 100 and 125 meningitis cas occur on college campus and as many as 15 students will die from the dia each year. Though it occurs most often in late winter or early spring, it can occur in any ason.
A vaccine is available to protect against four types of the bacteria causing meningitis
in the United States: types A, C, Y and W-135. The types account for nearly 2/3 of meningitis cas among college students. The vaccine does not protect against all strains of the dia and does not provide lifelong immunity. To help you make an informed decision about being immunized, talk with your health care provider to consider the benefits and risks of meningococcal meningitis immunization.
Though the University Health Service does not provide the vaccine on campus, we can refer students to local health care providers if requested. The cost of the vaccine varies, but in our area the approximate cost is about $100 – $200. Be advid that insurance may not pay for the cost of the vaccine.
For your information, we enclo a fact sheet about meningitis provided by the
New York State Department of Health. After reading the fact sheet and consulting
w ith your health care provider, plea complete the form we provide and return
it to this office. You may also fax the form to the number provided.
Thank you for taking the time to consider this important information about
Meningococcal Dia Information Sheet
Information for College Students and Parents of Children at Residential Schools and Overnight Camps
What is meningococcal dia?
Meningococcal dia is a vere bacterial infection of the bloodstream or meninges
(a thin lining covering the brain and spinal cord).
Who gets meningococcal dia?
Anyone can get meningococcal dia, but it is more common in infants and children.
For some college students, such as freshmen living in dormitories, there is an incread risk
of meningococcal dia. Between 100 and 125 cas of meningococcal dia occur
on college campus every year in the United States; between five and 15 college students die each year as result of infection.
Currently, no data is available regarding whether children at overnight camps or residential schools are at the same incread risk for dia. However, the children can be in ttings similar to college freshmen living in dormitories. Other persons at incread risk include houhold contacts of a person known to have had this dia, immuno-compromid people and people traveling to parts of the world where meningitis is prevalent.
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How is the meningococcus germ spread?
The meningococcus germ is spread by direct clo contact with no or throat discharges
of an infected person. Many people carry this particular germ in their no and throat without any signs of illness, while others may develop rious symptoms.
What are the symptoms?
High fever, headache, vomiting, stiff neck and a rash are symptoms of meningococcal dia. Among people who develop meningococcal dia, 10 – 15 percent die in spite of treatment with antibiotics. Of tho who live, permanent brain damage, hearing loss, kidney failure, loss of arms or legs or chronic nervous system problems can occur.
How soon do the symptoms appear?
The symptoms may appear two to 10 days after exposure, but usually within five days.
What is the treatment for meningococcal dia?
Antibiotics, such as penicillin G or ceftriaxone, can be ud to treat people
with meningococcal dia.
Is there a vaccine to prevent meningococcal meningitis?大班下学期计划
Yes, a safe and effective vaccine is available. The vaccine is 85 percent to 100 percent effective in preventing four kinds of bacteria (rogroups A, C, Y, W-135) that cau about
70 percent of the dia in the United States.
Is the vaccine safe? Are there adver side effects to the vaccine?
The vaccine is safe, with mild and infrequent side effects such as redness and pain at the injection site lasting up to two days.
What is the duration of protection from the vaccine?
After vaccination, immunity develops within ven to 10 days and remains effective
for approximately three to five years. As with any vaccine, vaccination against meningitis
may not protect 100 percent of all susceptible individuals.
How do I get more information about meningococcal dia and vaccination? Contact your family physician or your student health rvice. Additional information
is also available on the Web sites of: the New York State Department of Health,
www.us; the Centers for Dia Control and Prevention,
Meningitis Form
Student Health Services Queens and Manhattan Campus
8000 Utopia Parkway
Queens, NY 11439
Tel (718) 990-6360
Fax (718) 990-2368
www.stjohns.edu Name: _______________________________________________________ Date of Birth: _________________________Address: ________________________________________
____________________________________________________Student ID #: ________________________________________________________________________________________ St. John’s University is in compliance with New York State Public Health Law 2167, requiring all college and university students and parents or guardians (if student is under age 18) to complete and return this form to Student Health Services at the address above.
All students (and parents or guardians if student is under age 18) must complete and sign below. Plea note: It is necessary to complete this form even if documentation of this vaccine is already on file. CHECK ONE BOX AND SIGN BELOW:I have (for students under age 18: “My child has”):
had the meningococcal meningitis vaccine. Date: ______________________________________
Health Care Provider’s signature: ____________________________________________________
Address: ________________________________________________________________________
Licen # : _______________________________ Tel: __________________________________
Stamp: __________________________________________________________________________
read, or have had explained to me, the information regarding meningococcal meningitis dia. I understand the risks of not receiving the vaccine. I have decided that I (my child) will not obtain immunization against
meningococcal meningitis dia.
Staten Island campus Campus Center 300 Howard Avenue Staten Island, NY 10301Tel (718) 390-4447
Fax (718) 390-4480(Plea retain a copy for your files.)
Plea complete and return by January 15, 2011, to Student Health Services
作文寒假生活>蝎毒
at the campus where you are enrolled.
