VACCINATIONS DOCUMENTS

A HEALTH CARE PROVIDER MUST COMPLETE THE FOLLOWING
ALL TEST RESULTS MUST BE ATTACHED WITH THIS FORM

I. TUBERCULIN SKIN TEST
(Must be less than one year old. All tuberculin skin tests must be valid through the entire clinical clerkship)

For those with a history of a positive tuberculin test, the following is mandatory:

Chest XVray report: oPositive oNegative

II. IMMUNIZATION RECORD
(Students must prove immunity to ALL of the following prior to commencement of clinical clerkships)
HBsAb titer result: Positive/Immune/Past Exposure Negative/Non-Immune


I VERIFY THAT THE ABOVE INFORMATION IS TRUE


LICENSED SPECIALIST

GENERAL HEALTH

Surgeries
Drug or Food Allergies

Medication

MEDICAL HISTORY
Please check if you have ever had any of the following:
Headaches requiring treatment:  Ulcer/colitis:  Epilepsy/seizures:  Hepatitis/gallbladder disease: 
Asthma/lung disease:  Bladder/kidney problems:  Heart disease:  Diabetes: 
Anemia or bleeding disorder:  Cancer/tumors:  Back/joint problems:  Thyroid problems: 
High blood pressure:  Recurrent infectious diseases: 

CERTIFICATION
I certify that all responses made on this form are complete, true and accurate. I understand that if there are any changes in my health status, I will contact AICG immediately. I understand that if I misrepresented or failed to provide the information requested on this form, then I may be terminated from participation in or dismissed from my clinical clerkships.