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Revision June 2023 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 Contact Information: Health Services Center Albert A. Sheen Campus (St. Croix) Orville E. 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 understand 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, 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) Revision June 2023 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: Revision June 2023 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 (ACYW-135): __/__/__ **If Meningococcal ACYW is received before the age of 16, you will need an additional vaccine for residential living __/__/____ Covid Vaccine(ONLY if living on campus): Name: _________ Doses: / / /___/___/___ Booster: / / (Recommended not Required for any student to attend UVI) 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 _____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)