Caribbean School of Medical Sciences, Jamaica Medical Student Health Services 8 Waterloo Rd, Kingston Jamaica. Dear Prospective Student,

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1 Caribbean School of Medical Sciences, Jamaica Medical Student Health Services 8 Waterloo Rd, Kingston Jamaica Dear Prospective Student, CSMSJ would like to welcome you to the Caribbean School of Medical Sciences, Jamaica. You are eligible for our services once your school term begins. Enclosed you will find forms that MUST BE COMPLETED on your arrival. In addition you will need a copy of your immunization card and you will need certain blood investigations. All relevant forms must be sent in to the office no later than Date: Preadmission Requirements: Medical history form to be completed by the prospective student Physical eams are to be done at Winchester Surgical and Medical Institute, 3a Winchester Road, Kingston 10 Jamaica, which is also the designated for medical treatment, should in case such situations arise. If the medicals are been done from your country, all copies of results must be attached. These will be reviewed and to see if the requirements stipulated are in accordance with CSMSJ Health services and then a notification will follow via or otherwise. Immunization record completed and signed by your Health Care Provider. If you are require any further vaccination, you will notified of same and where to obtain them We look forward to meet you at the orientation. Sincerely Dr Neville Graham, OD, MD, FRCS (Edinburgh) President and Dean

2 To be completed by the student, please print in capital letters: Name: Gender: Female Male Date of Birth Marital Status SS# Address Cell Phone# Parent (Guardian) or Spouse: Permanent Address: Family History Current age Age at Death Health problems, or cause of death where applicable Grandfather Grandmother Father Mother Sister Brother AdditionalFamilyHistory: (Indicate the relationship) Breast Cancer Stomach Cancer Diabetes Mellitus Colon Cancer Aniety/Depression Tuberculosis Liver Disease Others Hypertension

3 PersonalHistory: ALLERGIES (describe) ALLERGIESTOMEDICATIONS: (eplain reaction) List all your CURRENT MEDICATIONS: (Include over the counter medications, birth control, herbal and vitamins, inhalers, devices and any sleeping aides in the space provided below Section 1: Name: Date: D.O.B T, P, R, BP, HGT cms, WGT kgs, BMI V/A (10 feet): Right eye -with glasses without glasses Left eye - with glasses without glasses Do you have any of the following? Diabetes Hypertension Tuberculosis Problems with lungs or pelvis. Aniety Depression Asthma Hepatitis A, B or C, UTI s Anaemia Other Heart or Kidney disease Kindly underline and eplain at what age

4 Do you wear or use any aids e.g. Contact lens, hearing aids etc. OTHER: Past Medical History: Past Surgical History: Do you smoke?: Alcohol History: Mental History: Hospitalization: For female: LMP Last Pap test ASSESSMENT NORMAL ABNORMAL NOTDONE EXPLAINANY ABNORMALITY DETECTED General Appearance Head Eyes

5 Ears, Nose, Throat Neck Skin Lymph Nodes Breasts Heart Lungs Abdomen Genitalia Rectum Spine Etremities Neuro Muscular Skeletal Additional Comments: INVESTIGATIONS: CBC, SICKLE, MSU and Urinalysis, Stool Section : 3 Vaccination History The following vaccines are required for all students (number through ) 1) MMR # 1 Date 1) MMR # 2 Date 2) Tetanus Tooid Date 3) BCG Date 4) Varicella Date 5) Hepatitis B Date

6 6) Polio Date OTHER Vaccines received, list with date: Date Date Date Date Print Name in bold Caps: Signature: Office Address: Office Telephone: Affi Stamp below: Section 4 : Dental History

7 Print Name in bold Caps: Signature: Office Address: Office Telephone: Affi Stamp below: Student Health Service Section 5: Patient Consent Permission For Medical Treatment I hereby authorize the Student Health Service of the Caribbean School of Medical Sciences, Jamaica to provide care and administer medical treatment necessary. Such care includes an assessment that will determine treatment of injuries or illnesses that may require administration of medication orally, or by injection. In case of medical or surgical emergency, I grant permission for legitimate care, if based on competent judgments concluded, delay will jeopardize my health. I am aware that the law protects confidentiality of HIV test results and other related information. The law also prohibits any discrimination based on an individual HIV status. Consent for HIV is mandatory at the Health Service of the Caribbean School of Medical Sciences, Jamaica unless I revoke it orally or in writing. I am aware that: HIV is the virus that causes AIDS and can be: Transmitted through unprotected se with someone who has the disease and eposure to other body fluid such as blood or sharing needle, piercing or tattooing. Transmitted to infants from HIV- Pregnant mothers during pregnancy, delivery or while breast feeding, Anonymous testing and Treatment for HIV/AIDS are available Safe practices can be adopted to protect uninfected persons from acquiring the disease. PERMISSION FOR RELEASE OF INFORMATION:

8 I hereby authorize the Student Health Service of the Caribbean School of Medical Sciences, Jamaica to disclose my health information in the following limited circumstances: Providing health care to me, for eample, they may share health information with individuals who provide or assist in the collaboration or management of my health care. Providing immunization records and /or laboratory test results only, for clinical rotations in the various clinical sites. I fully understand that I will need to provide additional written consent to have my medical records released under any other circumstances. PLEASEPRINTCLEARLYBELOW: Student Name Signature: Date:

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