Actcm Health Certificate printable pdf download

Health Certificate

Upon the acceptance at the American College of Traditional Chinese Medicine, the following health requirements must be completed by a qualified

Primary Health Provider prior to registration:

Student’s Name:

Birth Date

Please describe the overall health and any health problem(s) that will affect his/her being a student at ACTCM or working in the College’s

Community Clinic. Abnormalities should be described.

Overall:

Abnormal Findings:

Comments and Follow‐up

Primary Health Provider:

Name:

Signature:

Date:

Address:

City/State/Zip:

Phone: ( )

ALL STUDENT CANDIDATES ARE REQUIRED TO HAVE A TB TEST UPON ENTRY

Evidence of a current Tuberculin test MUST be submitted no later than 10 days of admission. Students with a history of a previous or current positive Tuberculin skin

test must submit a written report of a negative chest X‐ray taken within six months of the student’s first school quarter. A positive chest X‐ray requires physician

determination of non‐infectiousness prior to admission. Chest X‐ray are to be taken every 5 years. TB tests are to be taken annually.

Reader: ________________________________ Signature:



TB Test Given Date: __________________ TB Test Read Date:_________________

Results:

POSIVIVE

NEGATIVE

IMMUNITY RECORD

THE FOLLOWING SERUM TITRES OR VACCINES ARE RECOMMENDED

Date of Serum Titres

Results of Serum Titres

Date of Vaccine