Massachusetts College Of Pharmacy And Health Sciences

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 [email protected] or to [email protected] or fax to 1-214-619-1830 or 1-817-251- 9593. 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: [email protected] 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 NO To Student: Explain all YES Answers. MD/NP/PA Comments HAVE YOU EVER…. (questions 1-15) Identify by question # 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? 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 [email protected] KEEP A COPY FOR YOUR OWN RECORDS. Forms Due by August 15, 2014.

Measles, Mumps and Titer Dates (Required): Results of MMR Titers Vaccines: Rubella (MMR): Measles (Rubeola):____/____/____ (Required): Mumps: ____/____/____ Immune___Non-immune____ Documentation of two Rubella: ____/____/____ Immune___Non-immune____ MMR 1: ___/____/____ doses of vaccine or Immune___Non-immune____ immunity by serology. MMR 2:____/____/____

RubellaTiter: Rubella Titer Date: Proof of immunity by ____/____/______serology. Immune____Non-immune____ Tetanus Diphtheria, Pertussis (Tdap): Tdap Date: ____/____/_____ Within last ten years. Varicella: Proof of immunity by serology. Date of Titer: ____/___/____ Booster:____/_____/_____ History of disease is NOT Immune____Non-immune___ acceptable; a positive titer result meets the requirement. Hepatitis B: Proof of immunity by serology Hep B Surface Antibody Date: Dose 1: _____/_____/______/____/______Dose 2: ____/_____/_____ Dose 3: ____/_____/_____ Immune____Non-immune____ Booster:____/_____/_____

TB skin test TB Skin Test Date: Result: Neg_____Pos_____

(Annual PPD/Mantoux) _____/_____/______

If PPD is positive, chest x- ray is required. After submitting a normal chest x-ray at entry, an annual X-Ray Date: Result: Neg_____Pos_____ 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). Date:_____/______/______Influenza Vaccine due by:11/1/14 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 [email protected] 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: [email protected]

Any questions please email Sentry MD at [email protected] or call 1-800-633-4345 or visit our website at www.sentrymd.com.