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((lYjj) StGeorge'sUniversity
S C H 0 0 L 0 F M E 0 I C I N E
-- THINK BEYOND
August___January df2!J- May____Year___
MD MPH/MSc___Nursing____Premedical____CharterFoundation___
Part I
A. PERSONAL INFORMATION
Name (Print)
IDAOO._______
ast /
First Middle
Date of Birth Social Security No. 08l tDjt3pff6
Male
Female ____ V
Home Phone No. ___________ Cell Phone No. ..... r------
Home Address __
Number Street
City/Town State/Cou ntry ZipCode
Person to be notified in case of emergency:
ItieYancleJc
Nam Relationship
Home Phone No. ___________ Business Phone No. _____________
Cell Phone No.
CJ9f rCf3J
Address IUQ
, Swdh Ikon lk
tigf!-
Number Street

FL- 2W!1
CitylTown State/Country ZipCode
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------------------
Part I
B. HEALTH HISTORY
Name (Print)__ _______ _________________
'IJ;' I First Middle
Answer Yes or No to all questions below. IF the answer to any question below is yes, provide names and
addresses of all physicians or health care providers who participated in the diagnosis, referral, or treatment. Give
details, reasons, and dates as appropriate. Please use additional space below or additional pages, if necessary.
A. Has your physical actively been restricted or your education for medical, surgical, or psychiatric
reasons during the past three years? YES NO __
B. Do you have any physical disabilities or handicaps? YES ___ NO

C. Have you ever received treatment or counseling for a personality or character
disorder, or emotional problem? YES NO _____
D. had any illness or injury which required treatment or hospitalization by a physician or surgeon?
YES NO ____
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Part I
B. HEALTH HISTORY (continued)
E. List any medications you are taking regularly.
F. Do you use drugs or substances that alter your behavior? YES ____ NO_--=,--_
G. List any allergies and allergic reactions.
H. Do you have any condition which requires special consideration or treatment? YES ____ No,L
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Part I
B. HEALTH HISTORY(continued)
Pleaseindicateifyou havehadanyofthefollowing inthepast12months:
YES NO YES NO

Cough SoreThroat
.-/
'"--'"

/
Fever Skin Infection
...,/

NightSweats Rash
,/'
WeighLoss Nausea

Shortnessof Vomiting
/ /'
Breath
-- -.
-.:/-
..,/
Hemoptysis Diarrhea
Ifyestoanyoftheabove,pleaseexplaindetailsandcurrentstatus:
IdeclarethatIhavehadnoinjury, illness, orhealth conditionotherthanspecificallynotedaboveandwill notify
St. George'sUniversitySchoolofMedicineofanychangestomyhealthstatus.
Date: II ___
I I

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----
Part II: PHYSICAL EXAMINATION
Name(Print)__ -------------- ___ ___
\{Jt / First Middle
To theExamining Physician:
Please reviewthestudent's Health HistoryForm andcompleteapplicablepartsoftheexaminationform. Please
commentonall positiveanswersusingthebackofthispageoradditionalpages.
:;;J r;'2 )
Height__.=10 ___Weightr0b Blood Pressure
-------
Pulse
--------
Describeanyabnormalitiesofthefollowingsystemsinthespacebelow:
Eyes
cb
ENT
(j)
Neck
--
---+--dL
--
Lungs
ds
Heart
r1
Breast

Abdomen
v-


Rectum
c;D
---
NervousSystem
i(P
Genitalia
f\
Extremities

Ihavedeterminedthat________ is freefrom anyhealth impairment
whichis ofpotentialriskorwhich mayinterf r withtheperformanceofhis/herduties.This includesthe
habituationoraddictiontodepressants, s nts, narcotics, alcohol, orotherdrugsorsubstancesthatmay
altertheindividual'sbehavior.
(I
Date
CountryorStateLicense No.___-'C-_----''----_____
'CD.
)
-fAce..
Physician's Name(Please Print)
.;A09:::) z.=t 111
ex
Address
Number Street
N0fl\1>I'A- YL--
I
City/Town State/Country Zip Code
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_______ _______
Part III - TB SCREENING AND IMMUNIZATION RECORD
Name (Print)__ ..... ___ -.c::,{,c-:-' _
10 AOO_______
,1a"'-'o--'-S..LJ),(--.y_" -LKe..u' ________
Last ( First Middle
Date of
Social Security No. __ _____
, I '
PermanentAddress ___ __ ___ ___________________
Number Street
CitylTown State/Cou ntry Zip Code
To be completed and signed by a health care provider All dates should include month and year. Include the
manufacturer's name and lot number whenever possible.
A. MANDATORY TB SCREENING:
To be completed and signed by a health care provider. All dates should include month and year. Include the
manufacturer's name and lot number whenever possible, Please submit evidence of tuberculosis screening
completed within six months prior to registration. We accept the Mantoux skin test (PPD) or the QuantiFERON
blood test. The PPD must be indicated in millimeters. Students with a history of BCG vaccination or anti-
tuberculosis therapy are not excluded from this requirement
1. Intermediate PPD (STU Mantoux Test)
Date /;J ;2i) ,;;2011
Result mm. (Please indicate mm of induration)
PHYSICIAN / REGISTERED NURSE SIGNATURE _--+d1---1- ___ _
License No. __ _______\_J _____ State/Country _----=---rw_"-'-I'J-r_=}:;J-=-(il..::...._--"
If your QuantiFERON test or PPD is positive (> 10mm) now or by history, you need not repeat these. In this
case, the following statement must be Signed and dated by a physician and submitted along with the official
report of a recent chest x-ray. The exam and the chest x-ray must be done within three months prior to
registration date.
"I have been asked to evaluate the above named student because of a positive PPD. Based on the student's
history, my physical exam and recent chest X-ray (date ), I certify that the student is free of active
tuberculosis and poses no risk to patients."
PHYSICIAN / REGISTERED NURSE SIGNATURE ____________________
Physician's / Registered Nurse Name (Please print) ________________________
License No. _________ Date ________ State/Country ___________
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PartIII - TB SCREENING ANDIMMUNIZATIONRECORD (continued)
B. MANDATORYREQUIREMENTS
1. Measles, Mumps,Rubella, Varicella:
All studentsmustsubmitcopiesoflaboratoryresultsofserum IgG antibodytiterstomeasles, mumps,
rubella(MMR)andvaricella. Immunizationrecordsare NOTacceptedas proofofimmunity.Anylaboratory
resultswhich indicatenon-immunityrequireproofofadditionalvaccineadministration.
2. Tdap(Adecel)boosterwithinthelast 10years:
Date /,/,;It) ..YO/ / ManufacturerandLotNo., t?A.5br ,4 t./39;)6(:4
,
SignatureofHealthCare Provider Jlt'11U0/7 I .
3. HepatitisB
DocumentationofthreedosesofhepatitisBvaccine, andapositivehepatitisBsurfaceantibodytiterare
necessary.Alternatively, immunitymaybedocumentedbyapositivehepatitisBcoreantibody.Thehepatitis
Bvaccination is requiredforclinicaltrainingbutis notrequiredforregistrationattheUniversity. Ifthe
hepatitisBvaccination has notbeen receivedpriortoregistration, itwill needtobecompletedduringthe
firsttwoyears ofmedical school.ThismustbefollowedwithaserologyforhepatitisBsurface antibody.
HepatitisB: Threeimmunizationsat0, 1month, and6months:
Date________ ManufacturerandLotNo._____________________
Date________ ManufacturerandLotNo._____________________
SignatureofHealthCare Provider___________________________
Date________ ManufacturerandLotNo._____________________
AND
SerumAntibodyTiter(CopyofLab Results mustbesubmitted)
Date________ManufacturerandLotNo._____________________
Booster(ifnecessary)
Date________Manufacturerand LotNo._____________________
SignatureofHealthCare Provider___________________________
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Part III - TB SCREENING AND IMMUNIZATION RECORD (continued)
4. MeningococcalMeningitisVaccine:
Informationregardingthisvaccine maybereviewed atwww.cdc.gov/ncidod/dbmd/diseaseinfo
Checkoneboxandsign below:
D
Ihavereadtheinformationregardingmeningococcal meningitisdisease. Iwill obtainthevaccine
againstmeningococcalmeningitiswithin30daysfrommyprivatehealthcare provider.
ill ~ readtheinformationregardingmeningococcalmeningitisdisease. Iunderstandtherisksofnot
~ i v i n g thevaccine. IhavedecidedthatIwill notobtainimmunizationagainstmeningococcal
meningitisdisease.
DIhave hadthemeningococcal meningitisimmunization(MenomuneTM)withinthepast5years.
DateReceived _______SignatureofHealthCare Provider_______________
C. RECOMMENDEDIMMUNIZATIONS
1. Polio
a. Completedprimaryseries ofpolioimmunizations:
Dates_______
b. Booster
LiveVaccination(OPV)
Date_______ManufacturerandLotNo.______________________
SignatureofHealthCare Provider____________________________
Inactivated(IPV)
Date_______ Manufacturerand Lot No._____________________
2. HepatitisA
a. Twovaccinationsatleastsixmonthsapart:
Date_______ Manufacturerand LotNo._____________________
SignatureofHealthCare Provider____________________________
Date_______ Manufacturerand LotNo._____________________
SignatureofHealthCare Provider____________________________
b. Positiveserum antibodytiter:
Date_______ Manufacturerand LotNo.______________________
SignatureofHealth Care Provider___________________________
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Part III - TB SCREENING AND IMMUNIZATION RECORD (continued)
ADDITIONAL IMMUNIZATIONS
Student Signature Date --....... __---
SOM 02/10
- 9-
OCCUPATIONAL MEDICINE CENTERS OFAiYfERJCA
..
VACCINE CONSENT FORiYf
DATE: p-/)CJ/II
rl
NAME /)(NIA yJc,47
SOCIAL SECURITY: 0-1" - V-
- 3127
I
I UNDERSTANDTHERISKANDBENEFITS OFTHISITHESE VACCINE(S) ANDREQUESTTHAT
IT/THEYBE GIVENTOME.
1HAVE BEENGIVENTHEINFORMATIONPACKET(S)REGARDINGTHEVACCINE(S).
SIGNATURE:
DATE: 1:1- b6 It /
_________'..,=>_.....

VACCINE MFG.LOT INJECTIONSITE ADMINISTEREDBY
MMR#l
MMR#2
DIPHTHERlAJTETANUS .5C'tlC r? /;/1::;*",("
r2' /;Jc /
T' DCL? L/375C,C' /-J 6'YF}1/
.-L- Il) ....
TETANUSTOXOID
HEPATITISA#l
HEPATITISA#2
VARICELLA#1
,
VARICELLA#2
I
POLIO
YELLOWFEVER
PNEUMOVAX
-- ---- '--"=: __ - .. - - -- -- -
__=.o...-=r=c--,=''--'--=--=''-=---""""=--=-=
.
I
3705 Garfield Street Hollywood, FL 33021
Ph# 954-265-3406 Fcv.."# 954-265-2984 Email: occumedhlwd@hellsouth.llet
Occupotk>rdMedkIM
Centers t:I AmerkO
3705 GoI'fte'd StrMt
Hollywood. fL 33021
QS4.265.3406
BALANCE DUE
Invoice#: 10t
InvoiceDate: 121
MD: Tech 1,
Claim#:
Case#:
DOI/DOA:
Employer:
Charge
Amount Adjustment
18,00
30,00
22,00
35,00
40,00
65,00
210,00
(210,00)
0,00
OCCUPATIONiit MED tENi'ER3
3','05 GARFIELD STREET
HULLYJ.lOOO, fL j3U21
R.f II uU01
Sale
XXXXXXXXXXXX2268
VISA tntrY Method: Swiped
Total:
210.0(1
12/2Ml
10:29:04
Inv n: 0@0001
Appr Code: 042910
Apprvd: Online
Batch": 000221
IHANK YIIII'
Credit Check Credit
Amount Number Date
(18,00) Visa#042910
(30,00)
(22,00)
(35,00)
(40,00)
(6500)
***************************************
BALANCEDUE: 0,00
***************************************
L_BalDuelnv 12202011
PatientName: BOGDANSKY, KEVIN
PatientDOB: 05/13/1986
Soc, Sec,#: 031-72-3729
Diagnosis:
Guarantor: PrivatePay
Service
Date: Procedures
12/20/2011 TBtest. PPD
12/20/2011 Varicellatiter
12/20/2011 Rubellatiter
12/20/2011 Rubeolatiter
12/20/2011 MumosVirusAntibodv
12/20/2011 immunization- Tetanus/DiD/Pe
Code
86580
86787
85762
86763
86735
90721
TOTALCHARGES:
TOTALOTHERPAYMENTS:
TOTALADJUSTMENTS:
12/24/2011 Sat 12:11 EST. American HealthAssociates ID#53326
AMERICAN HEALTH ASSOCIATES
15712 SW 41 Street, Suite 16 Davie, FL 33331
954-919-5005
I CLIENT ACCOUNT: 3308 IPATIENT: BOGDANSKY, KEVIN IACC#:22399098 I
IOCCUPATIONAL MED CENTER IAGE: 25 GENDER: M ICOLL DATE&TIME: I
13705 GARFIELD ST IDOB: 05/l3/86 I 12/20/11 10:
IHOLLYWOOD, FL 33021 IPT TD: IRCVD: 12/20/11 I
1954-265-3406 ITEL: IRPTD: 12/24/11 I
I I I I
IREQUESTING PHYS:
IcHART: - -- - - - ------'-FASTING: UNKNowNI
I FLEIGELMAN, ROBERT MD I IPAGE: 1 I
I
---- ------ -- I I =-------c==--=--I
STATUS: FINAL
RES U L T S
I TEST - -- -----rwITHIN RANGE lOUT OF RANGE-jREFERENCE RANGE I UNITS
I
sVaricella-zoster Virus TgG Abs 2.45(H) < 0.91 Index
REFERENCE RANGE for Varicella-zoster IgG Abs:
Less than 0.91 Index . . . . . Kegati ve
0.91 - 1.09 Index .....Equivocal
Greater than 1.09 Index . . . Posi ti ve
A positive result indicates that the patient has antibody
to VZV. It does not differentiate between an active or
infcction. The clinical diagnosis must be interpreted in
conjunction with the clinical signs and symptoms of the
patient.
The presence of IgG VZV antibody IS consistent with
immunity.
R Mumps IgG Antibodies 1.63 (H) < 0.91 Index
REFERENCE RANGE for Mumps IgG Abs:
Less than 0.91 Index Negative
0.91 - 1.09 Index Equivocal
Greater than 1.09 Index positive
s Measles IgG Antibodies 6.27(H) < 0.91 Index
REFERENCE RANGE for Measles (Rubeola) IgG Abs:
Less than 0.91 Index. . Negative
0.91 - 1.09 Index Equivocal /r:)
Greater than 1.09 Index positive
s Rubella IgG Antibodies 44 (H) < 5 IU/mL
REFERF.NCE RANGE for Rubella IgG Abc;:
** Continued on Page 2 **
past
1
12/2412011 Sat 1211 EST American HealthAssociates 10: #53326

AMERICAN HEALTH ASSOCIATES 3MGdeId 8IrHt
Hollywood. FIortda 33Q21
15712 SW 41 Street, Suite 16 Davie, FL 33331
954-285-3406
954-919-5005
ICLIENT ACCOUNT: 3308 1PATIENT: BOGDANSKY, KEVIN IACC#:22399098 1
IOCCUPATIONAL MED CENTER IAGE: 25 GENDER: M 1 COLL DATE&TIME: 1
13705 GARFIELD
IHOLLYWOOD, FL
1954-765-l406
ST
33021
1DOB:
1 PT ID:
ITEL:
05/13/86 1 12/20/11
1 RCVD: 12/20/11
IRPTD: 12/24/11
10:
1
I
I __, ______1 1 I
IREQUESTING PHYS: ICHART: I FASTING: UNKNOWN1
1 FLEIGELMAN, ROBERT MD I I PAGE: 2 I
1--- ---------=-0=1
REPORT STATUS: FINAL
RES U L T S
TEST IWITHIN RANGEl OUT OF RANGE IREFERENCE RANGE IUNITS
< 5 IU/mL NONREACTIVE: Anti.body level may be
insufficent to provide protection
against Rubella virus infection.
5 - 9 IU/mL INDETERMINATE: Repeat "testing in 1-2
weeks may help clarify Rubella
antibody status.
> 9 IU/mL REACTIVE: Indicates current or past
infection or vaccination.
(5) - Test Performed At: SPECIALTY Lru30RATORIES
27027 TOURNEY ROAD
VALENCIA, CA 91355-5386
** End of Report ** DIRECTOR: JESUS E. VILORIA, M.D.