University Health Services
Pre-Matriculation Physical Evaluation Tier I-A, I-B & Tier II Programs
January 1, 2015
Dear Doctor:
Please complete the attached pre-matriculation physical evaluation and perform a physical examination for our
incoming student. The following is a list of REQUIREMENTS that must accompany this form. Please contact our
office at 215-955-6835 if you have questions. A copy of the results for all titers must accompany the form.
Requirements:
1. Measles Immunity as documented by a positive IgG antibody titers (copy must be attached).
2. Mumps Immunity as documented by a positive IgG antibody titers (copy must be attached).
3. Rubella Immunity as documented by a positive IgG antibody titers (copy must be attached).
4. Varicella Immunity as documented by:
a. Positive IgG antibody titer (copy must be attached); OR, Proof of 2 vaccines
5.Tetanus/Diphtheria/Pertussis Immunity as documented by:
a.A recent dose of the acellular pertussis/diphtheria/ tetanus booster (Tdap or Adacel) recommended within 5
years of your start date. Tetanus and Td are NOT valid.
6. Hepatitis B Immunity as documented by:
a. 3 doses of the vaccine and a positive hepatitis B surface antibody
7. Tuberculosis Screening
a.Quantiferon-TB Gold or T-SPOT (blood test) to be performed within 3 months prior to the start of your first
semester (copy of lab report must be attached). PPD will not be accepted
b.If positive PPD history along with INH treatment, a copy of a chest x-ray report done within the past 6 months
is required.
8. Meningitis Vaccination
a.Only students planning to reside in Jefferson housing must consider this vaccine. These students must
provide the date of vaccination or provide the signed waiver form available on our website.
9. Seasonal influenza vaccine is mandatory
a. Free flu vaccine will be provided by University Health Services during the Fall semester
b.If received outside of UHS, documentation is required. Include: date of vaccination, manufacturer, lot number,
expiration date, signature of administrator.
Sincerely,
Ellen M. O’Connor, MD
Medical Director, University Health Services
FORM 4950-NS (REV. 12/14)
Page 1 of 5
PRE-MATRICULATION PHYSICAL EVALUATION TIER I-A, TIER I-B & TIER II PROGRAMS
Last Name:
University Health Services
First Name:
Date of Birth:
/
/
Sex: 9 M 9 F
SS#:
-
-
Campus Key:
Current Address:
City:
State:
Zip:
State:
Zip:
Local Address:
City:
Home Telephone: (
)
Cell Phone Number: (
)
Jefferson E-mail Address:
@jefferson.edu
In case of an emergency contact - Name
Emergency Contact - Phone
(
)
Previous Jefferson Student? (If yes, give program and year of graduation)
9 No 9 Yes
Previous Jefferson Employee?
9 No
Previous visiting student or volunteer?
Employment Termination Date:
9 Yes
9 No
Current Jefferson Employee?
9 No 9 Yes
If yes, date of visit or assignment:
9 Yes
IF YOU DO NOT SEE YOUR PROGRAM LISTED, YOU HAVE THE WRONG FORM.
Program you are entering (please include Program on all correspondence)
Program
Start Date
Expected
Graduation Date
Graduate School of Biomedical Sciences
•
Postbaccalaureate Pre-Professional Program
School of Health Professions
•
•
•
•
•
Bioscience Technologies:
9 Bachelor
9 Masters
Couple and Family Therapy
Occupational Therapy: 9 BSMS
Physical Therapy:
9 EMOT
9 DPT
Physician Assistant Studies
• Radiologic Sciences
9 Bachelor 9 Masters (PET/CT & ICVT)
9 PET/CT Certificate
School of Nursing
9 PACE
9 FACT
9 BSN
9 Post-Master’s Certificate
9 APW to MSN
9 CRNA
9 MSN
9 MSN/MPH
9 DNP
School of Pharmacy
Sidney Kimmel Medical College
VERIFICATION OF INFORMATION
The following statements are true to the best of my knowledge. I understand that any false statement made purposely may be
grounds for dismissal from the program.
STATEMENT OF CONFIDENTIALITY
All medical records within University Health Services are confidential and will not be released without written authorization from
the student. For infection control purposes, I give my permission to have ONLY my immunization and/or tuberculosis screening
information forwarded for future participation in affiliate programs. This permission is in effect until I graduate from Jefferson or
leave my program. I am aware that I may revoke this permission at any time.
SignatureDate
FORM 4950-NS (REV. 12/14)
Page 2 of 5
PRE-MATRICULATION PHYSICAL EVALUATION TIER I-A, TIER I-B & TIER II PROGRAMS
University Health Services
Name (Print)
Date of Birth
/
/
Graduation Year
Program
Medical History: Do you have, or have you ever had any of the problems listed below? (please check)
9 Asthma
9 Wheezing
9 Chronic Cough
9 Coughing of blood
9 Shortness of breath
9 Pneumonia
9 Emphysema
9 Tuberculosis
9 High Blood pressure
9 Rheumatic fever
9 Heart murmur
9 Heart attack
9 Chest pain
9 Angina
9 Night Sweats
9 Palpitations
9 Leg swelling
9 Phlebitis
9 Kidney stones
9 Blood in urine
9 Urinary tract infection
9 Difficulty with urination
9 Sexually transmitted
disease
Do you have any medical problems not listed above?
9 Syphilis
9 Stroke
9 Persistent dizziness
9 Persistent headache
9 Seizure disorder
9 Loss of consciousness
9 Paralysis
9 Back trouble
9 Pain down leg
9 Numbness down leg
9 Abdominal pain
9 Hepatitis
9Y
9N
Please list specific problems:
Please list all surgical procedures:
Date
9 Jaundice
9 Gall bladder disease
9 Ulcer disease
9 Blood in stool
9 Vomiting blood
9 Persistent diarrhea
9 Anemia
9 Bleeding
9 Cancer
9 Visual difficulty
9 Hearing difficulty
9 Skin rash
Have you ever been hospitalized for any medical condition?
9Y 9N
If yes: Month(s)/Year(s) Reasons
Do you take medications regularly? 9 Y
Procedure
9N
If yes, please list (include vitamins, herbal supplements, birth control pills,
etc.)
Do you smoke?
Do you have allergies to medicine?
9 Arthritis
9 Gout
9 Thyroid disease
9 Diabetes
9 Undue fatigue
9 Excessive weight gain
9 Excessive weight loss
9 Depression
9 Anxiety
9 Eating Disorder
9 ADHD
9 Bipolar Disorder
9Y
9N
If yes, please list (include penicillin, sulfa drugs, tetracycline, etc.)
and include reaction:
9Y
9N
If yes, how many cigarettes per day?
/ day
If no, have you ever smoked?
Do you drink alcohol? 9 Y
9N
If yes, amount:
Do you have a history of alcohol or substance abuse? 9 Y 9 N
Do you have a sensitivity to latex? 9 Y
9N
If yes, explain:
If yes, please explain workup:
Do you have any physical, medical, or emotional problems that you
think may warrant special arrangements at school?
9 Y 9 N
Do you have any medical complaints now? 9 Y 9 N
Comments:
Comments:
FORM 4950-NS (REV. 12/14)
Page 3 of 5
PRE-MATRICULATION PHYSICAL EVALUATION TIER I-A, TIER I-B & TIER II PROGRAMS
University Health Services
Name (Print)
Date of Birth
/
/
Graduation Year
Program
Student Immunization Documentation
The following information is required prior to starting at Thomas Jefferson University.
To be filled out by Physician, Nurse Practitioner or Physician Assistant
Chicken Pox/Varicella
Mumps
Proof of immunity will mean documentation of two doses of
varicella vaccine OR serologic evidence of immunity (IgG)
Proof of mumps immunity will mean serologic evidence of
immunity (IgG)
Vaccine
Titer
OR
Titer
Date 1
Date 2
_____/_____/______
_____/_____/______
Date:
Result:
_____/_____/______
LAB REPORT MUST BE ATTACHED
Date:
Result:
_____/_____/______
LAB REPORT MUST BE ATTACHED
Hepatitis B Vaccine
Dose 1
_____/_____/______
Rubella
Dose 2
_____/_____/______
Proof of immunity to German Measles will mean serologic
evidence of immunity (IgG)
Dose 3
_____/_____/______
Titer
Date:
_____/_____/______
Result:
_____/_____/______
LAB REPORT MUST BE ATTACHED
LAB REPORT MUST BE ATTACHED
Tuberculosis Screening - IGRA Blood Test
Rubeola
Proof of immunity to measles will mean serologic evidence of
immunity (IgG)
Titer
Hepatitis B
Date
Surface Antibody
Result: Date:
Result:
_____/_____/______
Quantiferon-TB Gold OR T-SPOT within 3 months of the
start of semester. PPD will NOT be accepted
Date _____/_____/______
Result: LAB REPORT MUST BE ATTACHED
Positive History Only:
Meningococcal Vaccine
Date _____/_____/______
Chest x-ray within 6 months required for all positive results
(see page one for explanation)
Living in Jefferson Housing
9 Yes
9 No
Date of Vaccination
_____/_____/______
Date of Declination:
_____/_____/______
Attach form from website for declination.
Result: LAB REPORT MUST BE ATTACHED
Tetanus/Diphtheria/Pertussis (TDAP)
(recommended within 5 years of your start date)
Date of Tdap (Adacel) vaccination _____/_____/______
Influenza
Vaccination is required for students.
(Fall incoming students will receive in September)
Date _____/_____/______
MD/CRNP/PA-C Signature 
Date:
Printed Name:
Phone #: (
)
Address:
FORM 4950-NS (REV. 12/14)
Page 4 of 5
PRE-MATRICULATION PHYSICAL EVALUATION TIER I-A, TIER I-B & TIER II PROGRAMS
University Health Services
Name (Print)
Date of Birth
/
/
Graduation Year
Program
Physical Examination
BP
/
Pulse
Normal
Abnormal
Ht
ft.
in.
Wt
lb
Not
Remarks
Examined
General Health
Skin
Ears
EOMS
Pupils
Fundi
Nose/Mouth
Carotids
Thyroid
Lymph Nodes
Lungs
Heart
Abdomen
Extremities
Cranial Nerves
Motor
Sensory
Reflexes
Vision:
OD
OS
Color Blindness Screen: 9 Normal 9 Abnormal _____ # plates of Corrected: OD
OS
Date of Last Eye Exam:
To the best of my knowledge, based on my exam today, I believe this patient is:
9 fit to be a student
9 fit to be a student with the following restriction:
9 not cleared
MD/CRNP/PA-C Signature 
Date:
Printed Name:
Phone #: (
)
Address:
FORM 4950-NS (REV. 12/14)
Page 5 of 5