Xavier University
Radiologic Technology Program
Immunization Record
Name:__________________________ Date of Birth:_________________
Your physician Office must complete this section.
A. M.M.R. (Measles, Mumps, Rubella) Two doses required after 1956.
1. Dose 1 given age 12-15 months or later
Date: ___________________
2. Dose 2 given at age 4-6 years or later
Date: ___________________
B. TETANUS-DIPHTHERIA-ACELLULAR PERTUSSIA
1. Tetanus-Diphtheria-Acellular Pertussis (Tdap) booster within the last ten years.
Date: ___________
C. HEPATITIS B Vaccine - Three doses of vaccine or a positive Hepatitis surface antibody
Dose #1: Date_________
Dose #2: Date___________
Dose #3: Date __________
Or Hepatitis B surface antibody: DATE_____________________
Result:
Reactive ___________________ or Non-reactive ________________
D. VARICELLA - Either a history of chicken pox, a positive Varicella antibody, or two doses of
vaccine given at least one month apart if immunized after age 13 years (required).
1. History of Disease
Yes_____ Date: _______
2. Varicella antibody: Date:_________
Result: Reactive ___________________
or
or No _________
Non-reactive ________________
3. Varicella Immunization: Dose #1 Date:________________
Dose #2 Date:________________ given at least one month after first
dose, if age 13 years or older
continued health record of
:______________________ (name)
E. MENINGOCOCCAL (consider) One dose – preferably at entry into college for freshman living in
residence halls who wish to reduce their risk of meningococcal disease.
1. Dose #1 Date:_____________________
F. TUBERCULOSIS SCREENING - Requirement is a 2-step screening (see attachment)
1. PPD (Mantoux) Note: tine or monvac not acceptable
1st step results: Date: _________
negative_______ duration in mm:________ or Positive _________
2nd step results: Date: _________ negative______ duration in mm:_______ or Positive__________
If PPD is positive, chest x-ray required: X-ray results:
Normal ____________ Abnormal _____________
Date___________
Comments:
Healthcare Provider:_____________________________________________________
Address: _____________________________________________________________
Telephone: ________________
Physician Signature:____________________________ Date ______________________
Xavier University - Radiologic Technology Program
PHYSICAL EXAMINATION FORM
Patient’s Name: __________________________________________ Date of Birth: _________________
Visual Acuity:
Right Eye:
Without glasses 20/ ____
Left Eye:
Without glasses 20/ ____
With glasses
With glasses
20/_____
Normal
20/_____
Abnormal
SKIN
HEAD & NECK
EYES
EARS
NOSE
THROAT
MOUTH
THYROID
LYMPH NODES
BREAST
CHEST
RELEXES
Normal
Abnormal
HEART
ABDOMEN
SPINE
EXTREMITIES
VARICOSITIES
PERIPHERAL
ARTERIES & VEINS
NEUROLOGIC
GENERAL
IMPRESSION
Physical condition warrants assignment to full duty _________ or limited duty______.
If limited duty, list limits:
___________________________________________________________________________
___________________________________________________________________________
Physician’s signature: __________________________________________M.D.
Date: _________________________