Revised July 2022 STUDENT HEALTH FORM (Physical Examination section to be completed by a medical provider) FORM MUST BE COMPLETED AND UPLOADED TO THE MEDICAT PORTAL (https://uvi.medicatconnect.com) PRIOR TO MOVING ON CAMPUS OR REGISTERING FOR CLASSES Contact Information: Health Services Center Albert A. Sheen Campus (St. Croix) Orville K. Kean Campus (St. Thomas) RR#1 Box 10, 000 Kingshill #2 John Brewers Bay St. Croix, VI 00850-9781 St. Thomas, VI 00802-9990 (340) 692-4208 (Office) (340) 693-1124 (Office) INSTRUCTIONS: 1. Visit the Medicat portal (https://uvi.medicatconnect.com) and complete the a. UVI Health History form b. Texting Opt-in-Opt-Out form c. Enter the immunization dates on immunization tab d. Upload all health records including your physical exam, PPD (tuberculin skin test), and proof of vaccinations. 2. If you are under 18 years of age, a parent or guardian MUST complete and sign the Medical Consent Section of this Student Health Form. 3. Have a licensed medical provider (NP, MD, DO, or PA) fill out the physical examination section of this form including the required laboratory tests results. MEDICAL CONSENT (to be completed by the parent or guardian) I, the undersigned (parent or guardian) do hereby grant permission to the University of the Virgin Islands Health Service Center (personnel, medical providers and nurses, or the medical provider designated by the campus physician) to provide medical and or surgical treatment to: _____________________________________________ NAME OF CANDIDATE FOR ADMISSION during her/his enrollment at the University of the Virgin Islands. I also grant permission for her/his hospitalization and treatment herein, if such hospitalization is necessary. I understood that in the event of a serious illness, accidental injury or need for surgery, an attempt will be made by the University’s Health Service Center to contact me by telephone. If unable to contact me, needed emergency treatment may be given as necessary in the best interest of the student. _________________________________________________ _________________________________ SIGNATURE OF PARENT OR GUARDIAN DATE SIGNATURE OF STUDENT (IF OVER 18 YEARS OLD) (mo / day / year) Revised July 2022 PHYSICAL EXAMINATION SECTION Student Name ________________________________ DOB _____/_____/_____ ____Female ____ Male Height _______ Weight ______lbs BMI_______ Blood Pressure _____ /_____ T ____ P ______ R ____ Distance Vision: Right uncorrected: 20 /____ Right corrected 20 / ____ Left uncorrected: 20 / ____ Left corrected 20 / ____ Color Vision: ____ normal ____ abnormal Hearing (whispered voice at 10 feet): Right ____ heard ____ not heard Left ____ heard ____ not heard ALLERGIES: ______________________________________ SYMPTOMS: __________________________ SYSTEMS NL ABNL NA COMMENTS: HEENT HEART LUNGS ABDOMEN EXTREMITIES NEURO SKIN GENITAL(General PR Only) CURRENT MEDICATIONS: Name of Medication(s) Dosage How Often Discontinued 1. 2. 3. CURRENT MEDICAL CONDITION(S) AND TREATMENT(S): SURGICAL & PAST MEDICAL HISTORY: ADDENDUM: Revised July 2022 IMMUNIZATIONS: Required for all students Please upload proof of all below vaccines, lab, and PPD test results to the Medicat Portal on the upload tab Polio: ____/____/____ ____/____/____ ____/____/____ (3 doses acceptable) Tetanus, Diphtheria, Pertussis: Primary series completed? Yes____ No ____ Date of last dose in series: ____/____/____ Date of most recent booster dose: ____/____/____ Type of booster: Td_____ Tdap ____ MMR: ____/____/____ ____/____/____ Hepatitis B: ____/____/____ ____/____/____ ____/____/____ Meningococcal Quadrivalent (A, C, Y, W-135) ____/____/____ Serogroup B Meningococcal: ____/____/____ ____/____/____ routine _______ outbreak – related Covid Vaccine: Name: ___________ Doses: ____/____/____ ____/____/____ Booster: ____/____/____ Note: Negative covid test required periodically for covid unvaccinated students. Policy subject to change* Varicella: (A history of chicken Pox, a positive varicella antibody or 2 doses of vaccines meet the requirement): Dose #1 ____/____/____ Dose #2 ____/____/____ 1.  History of Disease: Year _______ or age ________ 2. Varicella antibody Date __/___/___ Result Reactive _____ non-Reactive____ PPD Skin Test is required for ALL students every 2 years. (Yearly for Nursing students in Clinicals). PPD or TST (Tuberculin Skin Test) ____/____/____ PPD Reading: ____/____/____ ____ mm Negative Positive CXR Results (required for positive PPD): ________  INH Treatment rec’d ____ 3 mons ____ 6 mons ____ 9 mons LABORATORY TEST RESULTS: CBC: _____________ UA: _____________ FBS: _____________  Lab Slip Given According to my review of systems, history and physical examination of the student: _____She/He/They are fit for any form of physical activity _____She/He/They should be excused from participation in strenuous physical activity _____She/He/They should be excused from participation in all forms of physical activity ______________________________________________________ ____________________________________ _________________________ MEDICAL PROVIDER NAME (Please Print) SPECIALITY AREA MEDICAL PROVIDER’S SIGNATURE: ________________________________ DATE: ___________ (mo / day / year) MEDICAL PROVIDER’S ADDRESS: ___________________________________________ ___________________________________________ ___________________________________________ UVI MEDICAL PROVIDER’S SIGNATURE: __________________________________ DATE: ___________ (mo / day / year)