Franklin Pierce University- Manchester, NH & Goodyear, AZ
These records must always be current.
Return forms to Sentry MD, P.O. Box 292575, Lewisville, TX 75029. You can email your forms to
universitystudent@sentrymd.com or to nicole.mischke@sentrymd.com or fax to 1-214-619-1830 or 1-817-2519593. The deadline to submit these forms is August 15, 2014.
Part I-Student Information: to be completed by the student
Name: (Please Print)
Franklin Pierce University Email Address
Last, First MI
Date of Birth: ____/_____/_____
Secondary Email Address
phone: (____) ______-_______
Campus Attending
Street Address
__Manchester
__Goodyear
City, State, Zip
Additional Documents to submit:
1. Professional Liability Insurance: Students must carry active Professional Liability Insurance while
attending Franklin Pierce University. Please submit confirmation of payment of your Professional
Liability Insurance Coverage along with this form.
2. Health Insurance: Students must submit a copy of your health insurance cards. Your health insurance
cards must show a current date within a year and your name. If you are a dependent and not on the
card or do not have a current date on them, you must provide additional documentation from your
provider showing you as a current active member.
3. CPR Certification: Students must carry active CPR Certification. Please submit a copy of your CPR
card.
4. First Aid Certification: Students must provide proof of First Aid to enter into the program. Please
submit a copy of your First Aid Card.
Franklin Pierce University works with Sentry MD, a confidential health information service. Sentry MD maintains
and processes all student immunization records and monitors compliance with state and program law requirements.
Students must send required immunization forms and certifications directly to:
Sentry MD, P.O. Box 292575, Lewisville, TX 75029
Fax: 1-817-251-9593 & 1-214-619-1830
Email forms to: universitystudent@sentrymd.com or nicole.mischke@sentrymd.com
Franklin Pierce University- Manchester, NH & Goodyear, AZ
Health History 2014-2015
Part II-Student Health History: to be completed by the student
Name____________________________________________________________ Date of birth: _____/_____/_____
Last
First
MI
YES
HAVE YOU EVER…. (questions 1-15)
1. Been hospitalized, had surgery, a serious or chronic illness or a
recent acute illness?
2. Had a head injury resulting in unconsciousness or temporary or
permanent memory loss (concussion)?
3. Fainted during or after exercise?
4. Had wheezing or other serious breathing problems during or after
exercise?
5. Had chest pain during or after exercise?
6. Had a neck injury or “stinger” (pins and needles sensation in one
or both arms after being hit in the head or neck?)
7. Been advised by a health care provider to avoid contact sports?
8. Had an allergic reaction to any medications? (Please list
medication and type of reaction)
9. Had or have any of the following medical conditions? Please circle
and explain) (a) asthma (b) anemia (c) tuberculosis (d) high blood
pressure (e) cancer (f) rheumatic fever (g) heart murmur (h) diabetes
(i) bladder or kidney disease (j) chicken pox (k)
stomach/gastrointestinal condition (l) hemophilia (m) sickle cell
disease (n) seizure disorder (o) thyroid disease (p) high cholesterol (q)
Kawasaki’s disease (r) absence of any organ(s) (s) learning disability
(t) mental illness/psychological disorder (u) anxiety/nervous condition
(v) depression
10. Had a parent or sibling with any of the following medical
problems? (Please circle) (a) heart disease or sudden death before
age 65 (b) cancer (specify type) (c) high cholesterol (d) phlebitis (e)
blood clotting disorder (f) asthma (g) anemia (h) Tuberculosis (i) high
blood pressure (j) diabetes (k) thyroid disease (l) mental
illness/depression
11. Experienced racing heart palpitations or skipped heart beats?
12. Been described as “double-jointed”?
13. Experienced “heat”-related illness?
14. Used steroids to improve athletic performance?
15a. Used marijuana, cocaine or other street drugs?
15b. Do you smoke cigarettes? If yes, how many/day?
15c. How much alcohol do you drink per week?
16. Are you presently taking any prescription, herbal or Over the
Counter medication? (Please list medication, dosage, and condition
for which prescribed)
17. Do you have any special dietary needs?
18. (a) Do you worry about your weight?
(b) Do you diet frequently?
(c) Are you preoccupied with food/eating?
19. Have you ever suspected or been told you might have an eating
disorder?
20. For Women: How many menstrual periods have you had in the
last 12 months?
21. Do you use any protective equipment or braces during exercise?
22. Have you ever sprained, dislocated, fractured or had other
significant injury of
(a) head/neck
(b) chest/back
(c) arm, hand, shoulder, elbow, wrist
(d) hip, thigh, knee
(e) calf, ankle, foot
PLEASE EXPLAIN: Give dates, details (right vs. left), symptoms
23. Do you have any other health complaints not mentioned above?
NO
To Student: Explain all YES Answers.
Identify by question #
MD/NP/PA Comments
Franklin Pierce University- Manchester, NH & Goodyear, AZ
IMMUNIZATION VERIFICATION 2014-2015
Name____________________________________________________________ Date of birth: _____/_____/_____
Last
First
MI
Part III- IMMUNIZATIONS: to be completed by your health care provider or student health service.
In order to promote and maintain a safe environment while in the Franklin Pierce University and clinical affiliate
sites, the following information is required prior to enrollment in the program. Please have the information in Part II
completed by your health care provider, former pediatrician or student health service. Submit the forms to Sentry
MD, P.O. Box 292575, Lewisville, TX 75029 or fax to 1-214-619-1830 or 1-817-251-9593 or email to
universitystudent@sentrymd.com KEEP A COPY FOR YOUR OWN RECORDS. Forms Due by August 15,
2014.
Measles, Mumps and
Rubella (MMR):
Documentation of two
doses of vaccine or
immunity by serology.
Titer Dates (Required):
Measles (Rubeola):____/____/____
Mumps: ____/____/____
Rubella: ____/____/____
RubellaTiter:
Proof of immunity by
serology.
Tetanus Diphtheria,
Pertussis (Tdap):
Within last ten years.
Varicella: Proof of
immunity by serology.
History of disease is NOT
acceptable; a positive titer
result meets the
requirement.
Hepatitis B: Proof of
immunity by serology
Rubella Titer Date:
____/____/______
Results of MMR Titers
(Required):
Immune___Non-immune____
Immune___Non-immune____
Immune___Non-immune____
Immune____Non-immune____
Tdap Date: ____/____/_____
Date of Titer: ____/___/____
Booster:____/_____/_____
Immune____Non-immune___
Hep B Surface Antibody Date:
____/____/______
Dose 1: _____/_____/____
Dose 2: ____/_____/_____
Dose 3: ____/_____/_____
Booster:____/_____/_____
If PPD is positive, chest xray is required. After
submitting a normal chest
x-ray at entry, an annual
note from your health care
provider that you are
symptom free or a repeated
normal chest x-ray will
satisfy the yearly test
required.
Influenza Vaccine:
(Required Annually).
Influenza Vaccine due
by:11/1/14
MMR 1: ___/____/____
MMR 2:____/____/____
Immune____Non-immune____
TB skin test
(Annual PPD/Mantoux)
Vaccines:
TB Skin Test Date:
Result: Neg_____Pos_____
_____/_____/______
X-Ray Date:
Result: Neg_____Pos_____
_____/______/______
Date:_____/______/______
Franklin Pierce University- Manchester, NH & Goodyear, AZ
Physical Exam 2014-2015
Part IIII- Physical Exam: to be completed by your health care provider or student health service.
NAME
L#
DOB
Students in Franklin Pierce University must be in a state of health that will allow them to participate in all clinical phases of the
program of study in a manner that will not jeopardize the health or safety of clients or themselves. The following items are to assist in
determining this requirement.
INSTRUCTIONS:
 Have Primary Care Provider complete this form
 Send completed original form to: Sentry MD, P.O. Box 292575, Lewisville, TX 75029 or Email to
universitystudent@sentrymd.com or fax to 1-817-521-9593 or 1-214-619-1830.
 Retain a copy of the completed form for your files
If the results are outside normal limits the student will be counseled by the program director regarding any implications that the results
may have for completion of program requirements.
VISION:
RIGHT vision (corrected)
LEFT vision (corrected)
HEARING:
Hearing Deficit RIGHT:  No  Yes
Hearing Deficit LEFT:  No  Yes
LIFTING:
Ability to lift 50 pounds and turn heavy objects: Unlimited? :  No  Yes
If no, provide written documentation from Primary Care Physician of limitations.
LIMITATIONS:
Are there any clinical situations, because of mental or physical limitations, this individual should not be
assigned to:  No  Yes If yes, please explain
CHRONIC CONDITIONS:
Does this individual have any chronic health problems:  No  Yes If yes, please explain
If yes, are these problems under appropriate medical supervision?
Please indicate any specific health conditions that faculty in the nursing program need to be aware of.
 None  Condition
Signature
Title
Physician, Advanced Nurse Practitioner or Physician’s Assistant
Date
Original Adoption by Faculty Association 1996; Revised and Readopted by Faculty Association 5/2/00; Revised by Faculty Association 9/14/2012
Franklin Pierce University- Manchester, NH & Goodyear, AZ
2014-2015
Student Checklist
1. Student information is complete in Part I.
2. Submit a copy of the following documentation:
 CPR Certification
 First Aid Certification
 Liability Insurance
 Health Insurance
3. Health History in Part II is complete.
4. Immunizations in Part III are complete with dates of titers/vaccines and results are signed by your Health Care
Provider.
5. Physical Exam is complete and signed by your Health Care Provider.
The above requirements are to be submitted to Sentry MD by August 15, 2014.
P.O. Box 292575, Lewisville, TX 75029
Fax: 1-817-251-9593 & 1-214-619-1830
Email forms to: universitystudent@sentrymd.com
Any questions please email Sentry MD at universitystudent@sentrymd.com or call 1-800-633-4345 or visit our
website at www.sentrymd.com.