Office of Health Services
222-05 56th Avenue, Bayside, New York 11364-1497
Room, MC-02 Tel. 718 631-6375 Fax. 718 631-6330
THE CITY UNIVERSITY OF NEW YORK
Medical Requirements for Massage Therapy
Please make two copies of all material. Health Services will NOT make copies for you.
- To be completed by Student -
Empl ID # ____________________ S.S. # XXX-XX-______________
Last 4-digits of Social Security #
Name ________________________, ________________________ Date of Birth ______ /______ /______
(Last) PRINT
(First) PRINT
Male □
Female □
MTF □
FTM □
Other □
Address ________________________________________ City __________________ State _______ Zip Code _________
E-mail ________________________________ Home # (________) ________-________ Cell # (_______) ________-________
- Below to be completed by Health Practitioner (MD, DO, NP, or PA) -
1. History and physical examination
2. Urinalysis
• Routine and microscopy (lab report required) or chemical dipstick (Health Practitioner note required)
3. QuantiFERON-TB Gold (QFTB-Gold)
• Chest x-ray report required only for positive QuantiFERON-TB Gold
4. Tdap (tetanus, diphtheria, acellular pertussis) vaccination: Date ____ /____ /____
5. Influenza vaccination (for current season): Date ____ /____ /____ Lot # __________ Exp. Date ____ /____ /____
6. Hepatitis B vaccination: Date # 1 ____ /____ /____ Date # 2 ____ /____ /____ Date # 3 ____ /____ /____
7. Hepatitis B surface antibody (HBsAb) titer (lab report required)
8. Hepatitis B surface antigen (HBsAg) titer (lab report required)
9. Complete blood count (CBC) with differential (lab report required)
10. MMR (measles, mumps, rubella) vaccine: Date # 1 ____ /____ /____ Date # 2 ____ /____ /____
11. Rubeola (measles) IgG titer (lab report required)
12. Mumps IgG titer (lab report required)
13. Rubella (German measles) IgG titer (lab report required)
14. Varicella IgG titer (lab report required)
15. Varicella vaccine: Date # 1 ____ /____ /____ Date # 2 ____ /____ /____
Health Practitioner Stamp Required
(MD, DO, NP, or PA)
Health Practitioner Signature ________________________
Office of Health Services
222-05 56th Avenue, Bayside, New York 11364-1497
Room, MC-02 Tel. 718 631-6375 Fax. 718 631-6330
THE CITY UNIVERSITY OF NEW YORK
Tuberculosis Screening
Please make two copies of all material. Health Services will NOT make copies for you.
- To be completed by Health Care Provider (MD, DO, NP, or PA) -
Empl ID # ____________________ S.S. # XXX-XX-______________
Last 4-digits of Social Security #
Name ________________________, ________________________ Date of Birth _____ /_____ /_____
(Last) PRINT
(First) PRINT
Male □
Female □
MTF □
FTM □
Other □
QuantiFERON-TB Gold (lab report required)
• Chest x-ray report required only for positive QuantiFERON-TB Gold
*All students with a history of positive TST or positive QFTB-Gold, including those who have previously received BCG
vaccination, are required to submit a chest x-ray (CXR) report to the Office of Health Services. Students who recently
converted to positive TST or positive QFTB-Gold should be offered prophylactic treatment unless medically
contraindicated to receive treatment. Student refusal of prophylactic treatment for LTBI must be indicated below.
Reason: ___________________________________________________________________________________________
Latent Tuberculosis Infection (LTBI) Treatment
Start Date ______ /______ /______ End Date ______ /______ /______
Health Practitioner Name ________________________, ________________________ Title __________ License # __________
(Last) PRINT
(First) PRINT
Address ________________________________________ City __________________ State ________ Zip Code _________
Office # (________) ________-________ Fax # (________) ________-________
Health Practitioner Stamp Required
(MD, DO, NP, or PA)
Health Practitioner Signature ________________________
Office of Health Services
222-05 56th Avenue, Bayside, New York 11364-1497
Room, MC-02 Tel. 718 631-6375 Fax. 718 631-6330
THE CITY UNIVERSITY OF NEW YORK
Medical Record for Massage Therapy
Please submit two copies and original of all material to Health Services. Health Services will NOT make copies for you. Whiteout renders forms null and void.
- To be completed by Student Student Contact Information
Empl ID # ____________________ S.S. # XXX-XX-______________
Last 4-digits of Social Security #
Male □
Female □
MTF □
FTM □
Name ________________________, ________________________ Date of Birth ______ /______ /______ Other □
(Last) PRINT
(First) PRINT
Address ________________________________________ City __________________ State _______ Zip Code _________
E-mail ________________________________ Home # (________) ________-________ Cell # (________) ________-________
Emergency Contact Information Name _______________________, _______________________ Relationship ____________________
(Last) PRINT
(First) PRINT
Home # (________) ________-________ Cell # (________) ________-________
*Check (√) any condition(s) and include medication(s) that applies*
Condition
Yes
Allergies
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Asthma
Cancer
Seizures
Diabetes
Drug/Alcohol Abuse
Ears/Nose/Throat
Neurologic
Fainting
Gastro-intestinal
Meds. No
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Condition
Heart
Injuries
Kidney
Musculoskeletal
Psychological
High Blood Pressure
STDs/STIs
Thyroid
Tuberculosis
Other
Yes
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Meds. No
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Briefly describe any condition checked “yes” and list subsequent medication(s): _________________________________
____________________________________________________________________________________________________________
List any surgeries or conditions not mentioned above and list subsequent medication(s): __________________________
____________________________________________________________________________________________________________
*Check (√) any physical handicap(s) and condition(s) that applies*
Wheelchair bound □
Use of crutch(s) or brace(s) □
Blind or Partially Sighted □
Neurologic impairment(s) □
Speech Impediment □
Deaf or Hard of Hearing □
Briefly describe any physical handicap(s): _______________________________________________________________________________
Please submit two copies and original of all material to Health Services. Health Services will NOT make copies for you. Whiteout renders forms null and void.
Name ________________________, ________________________ Date of Birth _____ /_____ /_____ S.S. # XXX-XX-___________
(Last) PRINT
(First) PRINT
Last 4-digits of Social Security #
Physical Examination
- To be completed by Health Practitioner (MD, DO, NP, or PA) -
Blood Pressure ________ Heart Rate ________ Height ________ Weight ________
Vision OU ________
Vision OD ________
Vision OS ________
Influenza Vaccination Date _______ /_______ /_______ Lot # ____________ Expiration Date ____________
System
Normal
Abnormal
Remarks (describe abnormalities)
Head / Neck
Eyes / Ears
Integumentary
Skeletal
Muscular
Digestive / Abdomen
Lymphatic
Respiratory
Endocrine
Neurologic
Circulatory / Cardiac
Reproductive / Urologic
Psychological / Emotional
Is student able to perform physical activity? Yes □ No □ If no, please describe why: __________________________________
____________________________________________________________________________________________________________
Is there any emotional or psychological condition(s) for which student is being treated? Yes □ or No □ If yes, please
describe: ___________________________________________________________________________________________________
Health Practitioner Name ________________________, ________________________ Title __________ License # __________
(Last) PRINT
(First) PRINT
Address ________________________________________ City __________________ State _______ Zip Code _________
Office # (_______) _______- _______ Fax # (_______) _______-_______
Date of Examination ______ /______ /______
Health Practitioner Signature ________________________
Health Practitioner Stamp Required
(MD, DO, NP, or PA)