Rose-Hulman Institute of Technology Health Services
5500 Wabash Ave. Terre Haute, IN 47803
PHONE 812-877-8367 FAX 812-872-6225 EMAIL healthservices@rose-hulman.edu
PHYSICAL EXAMINATION
1.
Instructions
A. All students entering Rose-Hulman Institute of Technology are REQUIRED to have a medical examination within the 12 months prior to arriving on
campus.
B. Parts One and Two of this examination are to be completed by the student. Part Three is to be completed by a provider, chosen by the student. The
examination is to be at the student’s expense. Complete Parts One and Two prior to the examination by the provider, as the provider will need to
review the information given.
C. Please return completed forms to: ROSE-HULMAN HEALTH SERVICES 5500 WABASH AVE. TERRE HAUTE, IN 47803 (812)877-8367 (812)872-6225 fax
PART ONE
GENERAL INFORMATION
2.
Basic Information (Please print or type)
A. Student Name:
___________________________________________________________________________________________
Last Name
First Name
Middle Name
Maiden
Home Address _________________________________________________________________________________
City ____________________________________________ State _______________ Zip ______________________
Home Phone __________________________________ Cell Phone _______________________________________
Date of Birth ____________________________________
B.
Gender ____________
Parent or Guardian Name:
____________________________________________________________________________________________
Last Name (father)
First Name
Middle Name
Home Address ________________________________________________________________________________
City _________________________________________ State _______________ Zip ________________________
Home Phone _________________________________ Cell Phone __________________________________
Email Address ________________________________________________________________________________
____________________________________________________________________________________________
Last Name (mother)
First Name
Middle Name
Home Address ________________________________________________________________________________
City _________________________________________ State _______________ Zip ________________________
Home Phone _________________________________ Cell Phone __________________________________
Email Address ________________________________________________________________________________
Signature of Student _________________________________________________ Date _________________________________
Signature of Parent(s) or Guardian (s) ___________________________________ Date _________________________________
Rose-Hulman Institute of Technology Health Services
5500 Wabash Ave. Terre Haute, IN 47803
PHONE 812-877-8367 FAX 812-872-6225 EMAIL healthservices@rose-hulman.edu
PART TWO
MEDICAL HISTORY
PRINT CLEARLY IN PEN OR TYPE ALL ANSWERS
_____________________________________________________________________________________________________________________________
Last Name
First Name
Middle Name
Maiden
_______________________________________
Date
1.
Family History
A. Relation
Age
State of Health
If deceased, cause of death & age at death
Father
_____
____________
___________________________________
Mother
_____
____________
___________________________________
Brothers
_____
____________
___________________________________
Sisters
_____
____________
___________________________________
Spouse
_____
____________
___________________________________
B. Has any blood relative had any of the following? (Check each item)
Yes
No
Relation (s) (Age of onset)
____
____
Cancer _____________________________________________________________________________
____
____
Diabetes ___________________________________________________________________________
____
____
Heart Trouble _______________________________________________________________________
____
____
Hypertension ________________________________________________________________________
____
____
Kidney Trouble ______________________________________________________________________
____
____
Mental Illness _______________________________________________________________________
____
____
Tuberculosis _________________________________________________________________________
2.
Personal History
Have you had or do you now have any of the following? ( place check at left of each item).
Yes
No
Yes
No
____
____
Anemia
____
____
Meningitis
____
____
Appendicitis
____
____
Mumps
____
____
Arthritis or Rheumatism
____
____
Asthma, Allergy
____
____
Pain in Chest
____
____
Painful or “trick” joints
____
____
Boils
____
____
Paralysis, Polio
____
____
Bone, Joint, or other Deformities
____
____
Pneumonia
____
____
Chicken Pox
____
____
Rheumatic fever
____
____
Chronic Cough
____
____
Scarlet Fever
____
____
Constipation
____
____
Severe Headaches/Migraines
____
____
Seizures
____
____
Ear, Nose, Sinus, Throat Trouble
____
____
Depression or Anxiety
____
____
Eye Trouble
____
____
Diabetes
____
____
Teeth or Gum Troubles
____
____
Diphtheria
____
____
Tuberculosis
____
____
Skin Trouble
____
____
Tumor, Cyst, Cancer
____
____
Stomach Trouble
____
____
Frequent Colds
____
____
Fainting Spells
____
____
Environmental Allergy
____
____
Foot Trouble
____
____
High or Low Blood Pressure
____
____
Frequent Trouble Sleeping
____
____
Jaundice
____
____
Frequent or Terrifying Nightmares
____
____
Loss of Limb
____
____
Whooping Cough
____
____
Other_______________________________
____
____
Gall Bladder Trouble
____
____
Heart Problems
____
____
Infectious Mononucleosis
____
____
Kidney Stones, Kidney Disease
____
____
Malaria
If yes to any of the above please describe ____________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
Rose-Hulman Institute of Technology Health Services
5500 Wabash Ave. Terre Haute, IN 47803
PHONE 812-877-8367 FAX 812-872-6225 EMAIL healthservices@rose-hulman.edu
3.
Brief Medical History
Yes
No
A.
1. Illness / Medical Condition
____
____
2. Have you had any serious injury?
____
____
3. Have you had any operations?
____
____
4. Have you been hospitalized within the last 12 months?
____
____
(If the is YES to any of the above questions, give dates and nature of medical conditions, injuries, operations, or treatment below).
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
B
1.
2.
Do you have any known sensitivity to food, chemicals, dust, sunlight, etc.? Yes ____ No ____
(If yes, describe) ___________________________________________________________________________________________________
Do you have known sensitivity to medications, vaccines, etc.? Yes____ No ____
(If yes, describe) Medication and what type of reaction
____________________________________________________________________________
3.
4.
5.
6.
Do you now wear glasses? Yes ____ No ____
Contacts? Yes ____ No____
Do you smoke? (If so, how much per day and for how long?)
_________________________________________________________________________________________________
Do you drink alcohol and how much? Is there a family history of Alcoholism? _________________________________________________
Do you use any illicit, non-illicit drug or ever had a history of drug use? ______________________________________________________
Do you take any medications? _______________________________________________________________________________________
If yes:
Medication:
Dose:
Frequency: (i.e. daily, twice a day, etc.)
Condition for which the med is taken
---------------------------------------------- ------------------------------------------------------ ---------------------------------------------------------------------------------------------- ------------------------------------------------------ ---------------------------------------------------------------------------------------------- ------------------------------------------------------ ---------------------------------------------------------------------------------------------- ------------------------------------------------------ ---------------------------------------------------------------------------------------------- ------------------------------------------------------ ---------------------------------------------------------------------------------------------- ------------------------------------------------------ ---------------------------------------------------------------------------------------------- ------------------------------------------------------ -------------------------------------------------
7.
8.
9.
10.
Do you regularly exercise? How much? ________________________________________________________________________________
Have you had a weight change in the past 12 months? Yes ____ No ____ If yes, how much? ______________________________________
Do you have a hearing problem? _____________________________________________________________________________________
Do you presently have any of the following which would require special accommodations?
Yes
No
a.
A physical disability
____
____
b. A mental disability
____
____
c.
A learning disability
____
____
If the answer is YES to any of the above questions, please give details) __________________________________________________
______________________________________________________________________________________________________________________________
11. FOR WOMEN – Is you menstrual cycle regular? _______________ Problems? _________________________________________________
_______________________________________________________________________________________________________________________________________
Rose-Hulman Institute of Technology Health Services
5500 Wabash Ave. Terre Haute, IN 47803
PHONE 812-877-8367 FAX 812-872-6225 EMAIL healthservices@rose-hulman.edu
PART THREE
MEDICAL EXAMINATION REPORT
(NOT required for Exchange Students)
Date____________________
_____________________________________________________________________________________
(Student Last Name)
(First Name)
(Middle Initial)
1.
Instructions
A. This part of the examination is to be completed by the examining physician.
B. This examination is at the student’s expense.
C. To the examining physician:
1. Please review the Report of Medical History.
2. Please complete all items.
2
Height __________
3
Clinical Evaluation
HEEENT
Chest and Lungs
Neurologic
Cardiovascular
Skin
Abdomen & Viscera
4
Weight __________
Blood Pressure _______________________
Normal
Abnormal
______
______
______
______
______
______
______
______
______
______
______
______
DOB ______________________________________
Pulse ________________________
Screening Lab Tests (as necessary)
1. Urine Analysis _____________________________________________________________________________________________________________
2. Complete Blood Count ______________________________________________________________________________________________________
3. Chest XRAY ____________ ___________________________________________________________________________________________________
4. Hearing Test (Audiogram)____________________ ________________________________________________________________________________
5. Vision Test ________________________________________________________________________________________________________________
Vision (uncorrected)
Right 20/ __________ (corr.) 20/ ___________ Left 20/__________ (corr.) 20/ _______ Near Vision R ______ L _______
Corrected R ____________ L _____________
5
Recommendations regarding health, physical activities, treatment, or special prescription:
6
7
In your opinion, may this student carry a full academic load? _______ Participate in athletics, if desired? _______
Is this student physically fit to participate in a normal college physical education class? _____________________
If you answered no, why not? _____________________________________________________________________________________________________
REMARKS:
Physician’s signature ____________________________________Address_____________________________Telephone Number______________________________