Alabama agricultural and mechanical university
Student Medical Examination Record Form
(256) 372-5600 (Telephone) (256) 372-5599 (Facsimile) Studenthealth@aamu.edu (E-mail)
Physical Examination: PHYSICIAN USE ONLY (The Student’s hard copy Vaccination Record MUST accompany this form)
Patient’s Full Name: __________________________________________ DOB: _______________________Today’s Date: _________________
Medical History Form Reviewed:
 Yes
 No
Signature: _________________________________________
Evaluations
Vital Signs
Normal
Abnormal
Blood Pressure
Temperature
Pulse
Weight
Height
Mood
Recommended Vaccinations
 Hepatitis B Series
 HPV
Immunization Report
Required Immunization
Immunization Date
Varicella (Chickenpox)
Tetanus (Td/Tdap)
MMR
Meningitis (If younger than 50 years old)
Date Administered
Date Read
Results
Skin Test
Tuberculin Test TB (PPD)
Chest X Ray (Only if
positive)
ATTENTION: Immunization Record and TB test verification MUST be
submitted with the Medical Form.
Normal
Abnormal
Normal
Abnormal
General Appearance
Chest
Skin
Cardiovascular
Head
Abdomen
Eyes
Genitalia
Ears
Lymphatic
Nose
Extremities
Throat
Musculoskeletal
Dental
Neurological
Physician’s Impressions or recommendations: _____________________________________________________________________________
Physical Activity Recommended?
 Yes
 No
Explain: __________________________________________________________
_____________________________________________________________________________________________________________________
_______________________________________________
Physician Signature
Date
_______________________________
License # and or Clinic Stamp
Per HIPPA (1996) guidelines, this form must be submitted directly to the
AAMU John & Ella Byrd McCain Student Health and Counseling Services
Please return completed form: via Mail (P.O. Box 98, Normal, AL 35762),
Fax (256-372-5599), or E-Mail (studenthealth@aamu.edu)
P.2 Revised Jan 8, 2015
Alabama agricultural and mechanical university
Student Medical Examination Record Form
(256) 372-5600 (Telephone) (256) 372-5599 (Facsimile) Studenthealth@aamu.edu (E-mail)
Medical History Form: To be completed by Student or Parent/ Guardian
Demographic Information
Last Name: ______________________________First Name: _______________________ Middle: __________________
Home Address: _______________________________City:______________________State:________Zip:____________
Home Phone: ____________________________ Alternate Phone: ___________________________________________
Social Security Number: _________________________Date of Birth: ___________________ Gender: _______________
For Emergency Notify: _____________________________________ Relationship: ______________________________
Home Phone: _____________________________Work: ___________________ Cell: ____________________________
______________________________________________________________________________________________
Student Medical History
Please mark Y (yes) and N (no) for each conditions or activities.
Y
Allergies
Chills
Sinusitis
Paralysis
Anemia
Diabetes
Thyroid
Anxiety
Eczema
Arthritis
Nausea
Insomnia
Asthma
Smoke
N
Y
Bronchitis
Joint Problems
Hemorrhoids
Dizziness
Chest Pain
Cancer
Convulsions
Meningitis
Depression
Constipation
Fainting
Dizziness
Nervousness/panic
Drink Alcohol
N
Y
Head Injury
Seizures
Back Pain
Ear Infections
Heart Disease
Tremors
Vomiting
Epilepsy
Chronic Cough
Chronic Colds
Pneumonia
Malaria
Appendectomy
Use Recreational Drugs
N
Y
N
High or low Blood Pressure
Fever
Kidney Stones
Excessive Fatigue
Chronic Swelling
Shortness of breath
Sexually Transmitted Disease
Frequent Urinary Tract Infections
Sickle Cell
Diarrhea
Hernia
Heartburn
Ulcers
History of Surgery or Hospitalizations: _______________________________________________________________________________________
Are your allergic to any medications, food, or other substances?
 Yes
 No
If yes, please list: ________________________________
__________________________________________________________________________________________________
List of all current medications:
Name
MG/ML
Dosage
1)
2)
3)
4)
__________________________________________
Student, Parent or Guardian’s Signature
____________________________________________________
Date
____________________________________________________________________________________
(DOCUMENT MUST BE COMPLETED WITH A PHYSICIAN SIGNATURE.
TURN PAGE FOR PHYSICIAN SIGNATURE)
P.1 Rev. January 8, 2015