DUE DATE JULY 15
TO THE STUDENT:
Please complete the front of this form before you go for your medical examination. This information is strictly for the use of the Student
Health Center and will not be released to anyone without your knowledge and consent.
This form should be returned to: Westminster College
Office of Admissions
New Wilmington, PA 16172-0001
ADMISSION PHYSICAL FORM
Full clearance for registration will not be granted until all medical requirements have been met.
SECTION 1
LAST NAME
FIRST NAME
ADDRESS
STREET
MIDDLE NAME
CITY
STATE
DATE OF BIRTH ZIP CODE
STUDENT CELL PHONE NO.
FATHER’S/GUARDIAN'S NAME
ADDRESS
TELEPHONE NO.
MOTHER’S/GUARDIAN'S NAME
ADDRESS
TELEPHONE NO.
ATTACH
PHOTO
HERE
HEALTH INSURANCE INFORMATION
HEALTH INSURANCE CO.
POLICY NUMBER
SUBSCRIBER NAME
GROUP NUMBER
SUBSCRIBER SS #
PLEASE ATTACH COPY OF INSURANCE CARD FRONT AND BACK.
I do not have health insurance. o
SEX
M
MARITAL STATUS
F
CITIZENSHIP
CLASS ENTERING
MS OTHER
HOME PHYSICIAN
PHONE
FAXADDRESS
Your Student Health Record is a private matter between you and your Health Care Provider. For your protection, information can only be released with
your permission.
Your health history is important. Carefully fill in the enclosed Family and Personal History form and mail it back to us. If you are under a doctor’s care
for a health condition, please ask that a summary be sent to the Student Health Center for inclusion in your Health Record.
REPORT OF MEDICAL HISTORY
SECTION 2
FAMILY HISTORY
STATE OF OCCUPATION
AGEHEALTH
HAVE ANY OF YOUR IMMEDIATE FAMILY HAD ANY OF THE FOLLOWING?
AGE AT CAUSE OF DEATH
DEATH
YESNO
RELATIONSHIP
tuberculosis
FATHER
diabetes
MOTHER
kidney disease
BROTHER
heart disease
high cholesterol
arthritis
SISTER
stomach/intestinal problem
asthma
seizures
cancer
List current medications and dosage
psychiatric problems
Drug allergies:
Other allergies:
1. Have you ever seen a counselor/therapist?
Yes
No
2. Have you ever been hospitalized for a psychiatric problem?
Yes
No
3. Do you have a health problem that is reflected in an emotional, physical, or
learning disability?
Yes
No
4. If yes, would you like to be contacted by one or more of the following people
so that you can learn about services and accommodations? (A check mark
signifies your consent to have your information sent to this person)
______ The Campus Nurse
______The Campus Counselor
______ The Director of Disability Resources
HAVE YOU HAD: Please make comments on reverse side.
YESNO
YES NO
YESNO
1.
chicken pox
16. anxiety
31. rupture, hernia
2.
chest pain/pressure
17.
insomnia
32. bipolar disorder
3.
palpitations
18.
seizure disorder
33. attention deficit
4.
high blood pressure
19. frequent colds
34. intestinal trouble
5.
heart murmur
20.sinusitis
35.tuberculosis
6.
mononucleosis
21. anorexia/bulimia 36. ear, nose, throat trouble
7.
recurrent headache
22. gallbladder trouble
37.jaundice/hepatitis
8.
head injury w/unconsciousness
23. urinary tract infections
38. sickle cell disease
9.
dizziness/fainting
24. venereal disease
39. joint disease or injury
10.
asthma
25. anemia
40. weakness or paralysis
11.
chronic cough
26. back problems 41. eye trouble
12. seasonal allergies
27. skin disorders
42. other health problems:
13. suicidal thoughts/attempts
28. tumor/cancer/cyst 43. do you smoke?
14. depression
29. gum/tooth trouble 44. Do you use alcohol?
15. sleep disorder
30. stomach problems
45. do you use drugs?
Surgical procedures and hospitalizations (please specify with dates):
Student’s Name______________________________________________ Date of Birth____________________________________
SECTION 3: IMMUNIZATION RECORD
1.
The following immunizations are REQUIRED and must be signed by health care provider:
1.
Tetanus/Diptheria/Pertussis Primary Series (4-5 shot series received in early childhood)
Dates administered: #1__________ #2__________ #3__________ #4__________ #5__________
2. Tdap (Tetanus with Pertussis) IMPORTANT! Must be within last 10 years. 3. Measles/Mumps/Rubella (MMR) - 2 doses are required or copy of documented positive titers
Date Tdap administered__________
Dates administered: #1__________ #2__________
4. Meningococcal - If initial dose administered at age 15 or younger, booster dose given between ages 16-18 is required. If initial dose administered at or
after 16 years old, booster is not required. 5. Polio Primary Series (4-5 shot series received in early childhood):
6. Dates administered: #1__________ #2__________
Dates administered: #1__________ #2__________ #3__________ #4__________ #5__________
Varicella Dates administered: #1__________ #2__________
OR Date of illness:__________
OR Titer date:__________ Result (circle one) POSITIVE NEGATIVE
2. SUGGESTED IMMUNIZATIONS
1. Hepatitis B Series Dates administered: #1__________ #2__________ #3__________
2. Hepatitis A Series Dates administered: #1__________ #2__________ #3__________
3.
Pneumococcal Dates administered: #1__________ #2__________ #3__________
4. HPV Dates administered: #1__________ #2__________ #3__________
5. Influenza Dates administered: 6. Other immunizations ________________________________________________________________________________________________________
#1__________ #2__________ #3__________
3. TB SCREENING (REQUIRED)
Risk Assessment
1. Does the patient have s/s of active TB?
2. Has the patient had close contact with anyone with infectious TB? Y
3. Has the patient had contact with anyone recently in jail, with HIV
infection, or IV drug user?
4. Y
Y
N
N
N
Has the patient resided in, been an employee of, or volunteered in a high
risk congregate setting (prison, nursing home, hospital, homeless shelter)? Y
5. 6. N
7. Has the patient spent an extended period of time outside the US or Canada?
Y
If yes, what country?___________________________
8. Other indications?______________________________________________
9. Has the patient ever had a positive TB skin test?
If yes: when_______________ Date/result chest x-ray_________________
Treatment Plan___________________________________________________
* A “yes” response to any of the above questions, except #9, requires a TB
N
Y
N
Skin test (ppd mantoux only)
Does the patient have a high risk clinical condition (HIV, renal failure)? Date of test__________________ Date read_____________________
Y
Result in mm______________________ (Read in 48-72 hours)
N
Is the patient foreign born?
Y
N
A chest x-ray with physician treatment plan is required for positive results
Print Name of Physician
Signature of Physician
Date
Student’s Name______________________________________________ Date of Birth____________________________________
• Exam must be within past year. Should not be done by a parent physician.
SECTION 4: PHYSICAL EXAMINATION
Date of Exam________________________________
Temp
Ht
PulseBP
NORMAL ABNORMAL Wt
DESCRIBE ABNORMALITIES
Head, Ears, Nose and Throat
Respiratory
Cardiovascular
Gastrointestinal
Eyes
Genitourinary
Musculoskeletal
Metabolic/Endocrine
Neuropsychiatry
Skin
Current Medications:_________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________
Medication Allergies:_________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________
Is this student under treatment for any physical conditions________________________________________________________________________________________________
Cardiac Hx (murmur, palpitations, long QT syndrome, hypertension)_______________________________________________________________________________________
Family Hx of nontraumatic sudden death before age 50?
Yes oNo o________________________________ Family Hx of Marfan Syndrome?Yes oNo o
Prior Exertional Chest Pain?_____________________________________________________ Prior Exertional Syncope?________________________________________________
Head Injury Hx (previous concussions or LOC, number and severity of episodes_____________________________________________________________________________
Pulmonary Hx (Asthma, EIA, etc.)__________________________________________________________________ Regular Peak Flow Spirometer use?Yes oNo o
Heat Stress Hx (Dehydration, Heat Exhaustion, Heat Stroke)______________________________________________________________________________________________
PARTICIPATION IN ATHLETICS
This student is medically cleared to participate in intercollegiate athletics
Yes oNo o
This student is cleared to participate in physical education courses
Yes oNo o
List any limitations for performance ___________________________________________________________________________________________________________________
Printed Name of Physician_________________________________________________________________________ Date__________________________________________
Signature of Physician____________________________________________________________________________ Date _________________________________________
Address_________________________________________________________________________________________ Phone number_________________________________
I give permission to disclose the information contained in the above statement to Westminster College‘s Athletic Department.
Student Signature____________________________________________________________________________________________________________________________________