SAINT CHARLES BORROMEO SEMINARY
100 EAST WYNNEWOOD ROAD, WYNNEWOOD, PENNSYLVANIA, 19096
Medical History and Physician’s Report
LAST NAME
FIRST NAME
SOCIAL SECURITY NUMBER
SPONSORING DIOCESE
MIDDLE INITIAL
DATE OF BIRTH
Contact Information
STREET ADDRESS
P.O. BOX
APARTMENT NUMBER
CITY
STATE
ZIP CODE
HOME PHONE
CELL PHONE
EMAIL ADDRESS
WORK PHONE
WEBSITE
Emergency Contact
NAME (FIRST, MIDDLE
INITIAL, LAST)
RELATIONSHIP TO
APPLICANT:
STREET ADDRESS
P.O. BOX
APARTMENT NUMBER
CITY
STATE
ZIP CODE
HOME PHONE
CELL PHONE
WORK PHONE
EMAIL ADDRESS:
In case of serious emergency/illness students are sent to local hospitals. The student, or if a
minor, the parent/guardian, will be accountable for all hospital fees and follow up treatment.
I give permission to the person/persons in charge to secure for me or my minor child
appropriate medical treatment.
STUDENT SIGNATURE
PARENT/GUARDIAN SIGNATURE (if minor)
_______________________________
Date: _________________
_____________________________________
Date: ___________________
Revised December 2014
Student Name: _________________________________________________________________________
CONSENT FOR TREATMENT
(Required for students under 18)
I hereby give consent for my minor child, _________________________________ to receive routine care
at the student health infirmary and in the event of an EMERGENCY, give permission to SCS personnel
and the hospital to secure appropriate treatment for this minor.
________________________________________________ (Parent/Guardian signature)
(Required for students 18 and older)
In the event of an EMERGENCY, I hereby give permission to SCS personnel and the hospital to secure
for me appropriate treatment.
________________________________________________(Student signature)
Allergies – Please list all drug, food, environmental, or other allergies.
Medications – are you currently taking any medications? (Include any over the counter medications)
CONDITION
MEDICATION
CONDITION
MEDICAL HISTORY AND PHYSICIAN’S REPORT
MEDICATION
2
Student Name: _________________________________________________________________
Family History
STATE OF
AGE HEALTH
OCCUPATION
AGE AT
DEATH
CAUSE OF DEATH
FATHER
MOTHER
BROTHERS:
SISTERS:
Have any of your relatives ever had any of the following?
ILLNESS
YES
NO
RELATIONSHIP
TUBERCULOSIS
DIABETES
KIDNEY DISEASE
HEART DISEASE
ARTHRITIS
STOMACH DISEASE
ASTHMA/HAY FEVER
CANCER
HIGH BLOOD PRESSURE
HIGH CHOLESTEROL
STROKE
NEUROLOGICAL
DISORDERS
(E.G. ADD/ADHD/DYSLEXIA)
MENTAL ILLNESS
SEIZURES/EPILEPSY
MEDICAL HISTORY AND PHYSICIAN’S REPORT
3
Student Name: ________________________________________________________________
Personal History
Please answer all questions. Comment on all positive answers in the space below or on a supplemental
sheet.
HAVE YOU HAD:
SCARLET FEVER
MEASLES
YES NO
HAVE YOU HAD:
RHEUMATIC FEVER
ALBUMIN/SUGAR IN
URINE
GERMAN MEASLES
SKIN RASHES/SORES
MUMPS
MARFAN’S SYNDROME
CHICKEN POX
TUBERCULOSIS
INFECTIOUS
MONONUCLEOSIS
HIGH OR LOW BLOOD
PRESSURE
ELEVATED
CHOLESTEROL LEVEL
HIGH OR LOW BLOOD
SUGAR/DIABETES
HEART MURMUR
PAIN/PRESSURE IN
CHEST
PALPITATIONS/IRREG.
HEART BEAT
SHORTNESS OF
BREATH
PNEUMONIA
CHRONIC COUGH
RECURRENT COLDS
RECURRENT SINUS
INFECTIONS
DEVIATED SEPTUM
ASTHMA
YES
NO
HAVE YOU HAD:
FREQUENT ANXIETY
DEPRESSION
OBSESSIVE COMPULSIVE
DISORDER
FREQUENT
NAUSEA/VOMITING
STOMACH OR
INTESTINAL PROBLEM
HERNIA
RECTAL
PROBLEM/HEMORRHOID
GALLBLADDER
DISEASE/GALLSTONE
JAUNDICE
RECURRENT URINARY
TRACT INFECTION
PROSTATITIS/
EPIDIDYMITIS
KIDNEY STONES
EYE/VISION
PROBLEM
PHLEBITIS
HEARING PROBLEM
NEURITIS/
NEURALGIA
MIGRAINE
HEADACHES
SEIZURE DISORDER
VARICOSE VEINS
RECURRENT
HEADACHES
HEAD INJURIES WITH
UNCONSCIOUSNESS
DYSLEXIA
FREQUENT URINATION
“TRICK” KNEE,
SHOULDER
CANCER
FREQUENT EAR
INFECTIONS
HOARSENESS
TUMOR, CYST
OTHER LEARNING
DIFFERENCES
INSOMNIA
BACK PROBLEMS
FEVERS/SWEATS
TICS
WEIGHT LOSS/GAIN
EATING DISORDERS
ANOREXIA/BULIMIA
WEAKNESS, PARALYSIS
DIZZINESS/FAINTING
YES NO
SEXUALLYTRANSMITTED DISEASE
ARTHRITIS/ARTHRALGIA
BURSITIS
ADD/ADHD
IMMUNE DEFICIENCY
OTHER BLOOD
DISORDER
DO YOU BLEED OR
BRUISE EASILY?
(IF SO, IS THIS NEW?)
ANEMIA
Comments:
MEDICAL HISTORY AND PHYSICIAN’S REPORT
4
Student Name: ____________________________________________________________________________
Surgery and/or Hospitalizations:
SURGERY
TYPE OF SURGERY
YEAR
HOSPITALIZATIONS
REASON
YEAR
TRANSFUSIONS OR BLOOD PRODUCTS EVER RECEIVED? KIND?
YES
NO
LAST EKG
LAST CHEST X-RAY
OTHER X-RAYS IN THE LAST
FIVE YEARS
LAST GENERAL PHYSICAL EXAMINATION
LAST GENERAL BLOOD STUDIES
WHEN WAS YOUR LAST RECTAL EXAM?
Do you wear eyeglasses or contacts? _____________ When was your last vision test? _________________
Do you use a hearing aid? ___________________ When was your last hearing test? __________________
How would you describe your appetite? Good:__________ Fair: ____________ Poor: ______________
Approximately how many urinary trips do you make during the: Day? ___________ Night? __________
Have you ever had alcohol or drug addiction? _____________ Treatment? _________________________
Do you drink alcoholic beverages? _________ If yes, indicate the frequency _________________________
Do you now, or have you in the past, used illegal drugs? ____________. If yes, indicate the kind and
frequency of use: __________________________________________________________________________
MEDICAL HISTORY AND PHYSICIAN’S REPORT
5
Student Name: ___________________________________________________________________________
Symptoms: Do you have or have you had any of the following symptoms within the past year?
Comment on all positive answers in the space below or on a supplemental sheet.
SYMPTOM
YES
NO
SYMPTOM
HEADACHES
SORE THROAT
FAINTING SPELLS
SORE, EASILYBLEEDING GUMS
UNCONSCIOUSNESS
BLOOD IN BOWEL
MOVEMENTS
VISION TROUBLE
RINGING IN EARS
DECREASED
HEARING
NOSE BLEEDS
YES
NO
CHANGE IN DIAMETER
OF BOWEL
MOVEMENTS
PAIN WITH BOWEL
MOVEMENTS
CHANGE IN COLOR OF
BOWEL MOVEMENTS
ACCIDENTAL LOSS OF
URINE
FREQUENT COLDS
EASY TIRING
SINUS TROUBLE
CHEST PAIN
ALTERED TASTE OR
SMELL
COUGHING BLOOD
HOARSENESS
RECURRING COUGH
DIFFICULTY
SWALLOWING
ENLARGED
GLANDS; LUMPS
SHORTNESS OF
BREATH
PURPLE LIPS AND/OR
FINGERS
SYMPTOM
YES
HEART
FLUTTER
HIGH BLOOD
PRESSURE
ANKLE AND/OR
FOOT
SWELLING
LEG CRAMPS
ENLARGED LEG
VEINS
ABDOMINAL
PAINS
BELCHING;
HEARTBURN
NAUSEA;
VOMITING
VOMITED
BLOOD
AVERSION TO
ANY FOODS
NUMBNESS OR
TINGLING
RASHES
URINARY
SYMPTOMS
Comments:
MEDICAL HISTORY AND PHYSICIAN’S REPORT
6
NO
Student Name: ___________________________________________________________________________
Physical Examination
EXAMINING PHYSICIAN: PLEASE REVIEW THE APPLICANT’S HISTORY AND COMPLETE
THE FOLLOWING PAGES.
PLEASE COMMENT ON ALL ABNORMAL RESULTS.
N=NORMAL
ABNORMAL=PLEASE COMMENT
X=NOT EXAMINED
HEIGHT-INCHES
WEIGHT-POUNDS
OVERWEIGHT UNDERWEIGHT
BLOOD
HEART
HEART RATE
PRESSURE
RHYTHM
EYES
FUNDI
UNCORRECTED VISION
NEAR:
DISTANT:
CORRECTED VISION
NEAR:
DISTANT:
OTHER COMMENTS REGARDING VISION:
EARS
NOSE
THROAT
FACE
MOUTH
CHEST (EXCURSIONS)
NECK
HEART
SKIN
ABDOMEN, INGUINAL, FEMORAL
HERNIA
BACK AND SPINE
ARMS
LEGS
NEUROMUSCULAR
GENITOURINARY
RECTAL
PROSTATE
GENITALIA
MUSCULOSKELETAL
METABOLIC/ENDOCRINE
NEURO-PSYCHIATRIC
GASTROINTESTINAL
HEARING
MEDICAL HISTORY AND PHYSICIAN’S REPORT
7
Student Name: ___________________________________________________________________________
PHYSICIAN – GENERAL COMMENTS:
IS THE PATIENT PRESENTLY UNDER TREATMENT FOR ANY MEDICAL OR EMOTIONAL
CONDITIONS? YES NO
PLEASE EXPLAIN:
IS THERE LOSS OR SERIOUSLY IMPAIRED FUNCTION OF ANY LIMB OR ORGAN?
PLEASE EXPLAIN:
RECOMMENDATIONS FOR PHYSICAL ACTIVITY (PE,
INTRAMURALS, SPORTS):
PLEASE EXPLAIN:
UNLIMITED
DO YOU HAVE ANY RECOMMENDATIONS REGARDING THE CARE OF
THIS STUDENT?
PLEASE EXPLAIN:
MEDICAL HISTORY AND PHYSICIAN’S REPORT
YES
YES
NO
LIMITED
NO
8
Student Name: ________________________________________________________________
Immunizations (Vaccines)
THE FOLLOWING ARE THE IMMUNIZATION REQUIREMENTS FOR REGISTRATION AT
SAINT CHARLES BORROMEO SEMINARY, AS RECOMMENDED BY THE PENNSYLVANIA
DEPARTMENT OF HEALTH.
VACCINE DATE
DTP/DTaP (DIPHTHERIA,TETANUS,
PERTUSSIS)
BASIC SERIES OF THREE
TD or Tdap BOOSTER WITHIN 10 YRS.
POLIO: THREE DOSES IF UNDER AGE
18 YRS.
VARICELLA: EITHER A HISTORY OF CHICKEN POX, A POSITIVE VARICELLA TITER, OR
TWO DOSES OF VACCINE GIVEN AT LEAST ONE MONTH APART IF IMMUNIZED AFTER
AGE 13. DATES PLEASE
DATE OF POSITIVE
DOSE #1
DOSE #2
DATE OF DISEASE
TITER (ATTACH
LAB)
DATE:
DATE:
DATE:
DATE:
M.M.R. (MEASLES/MUMPS/RUBELLA): TWO DOSES REQUIRED OR DOCUMENTED
HISTORY OF DISEASE, OR POSITIVE TITER FOR ANY OF THESE DISEASES.
DATE OF DOSE #1: __________________
MEASLES:
DATE OF DOSE #2: _________________
RUBELLA (GERMAN
MEASLES):
MUMPS:
DATE OF DISEASE:
DATE OF POSITIVE
TITER:
(PLEASE ATTACH
LABS)
HEPATITIS B: ALL ENTERING STUDENTS SHOULD HAVE BEGUN OR COMPLETED THE
HEPATITIS B VACCINE SERIES OF THREE DOSES. POSITIVE HEPATITIS B SURFACE
ANTIBODY MEETS THE REQUIREMENT.
PLEASE INDICATE THE DATES OF VACCINATION
DOSE 1:
DOSE 2:
DOSE 3:
HEPATITIS B SURFACE
ANTIBODY
DATE:
RESULT
MENINGOCOCCAL QUADRIVALENT: Pennsylvania State Law requires all student of 21 yrs. and
younger living on campus to have documentation of a dose of conjugated vaccine at 16 years or older. Obtain
the vaccine or sign a waiver that you decline it. Also for any student who wishes to protect themselves, or
persons with complement deficiency/splenic.
VACCINE TYPE:
DATE GIVEN:
MEDICAL HISTORY AND PHYSICIAN’S REPORT
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Student Name: ____________________________________________________________________________
Required Tests: TUBERCULOSIS SKIN TEST (PPD) within last twelve months
Placement Date: _______________ Date and Results: ___________________________
A Chest X-Ray if skin test was positive. Date of chest X-Ray: ___________ Results: ____________
LABORATORY TESTS
CBC
CMP
HIV
TSH, T3, T4
LIPID PANEL
URINALYSIS
Additional Remarks or Comments by examining Physician:
Physician’s Information
NAME (PLEASE PRINT)
TELEPHONE:
FAX:
CITY
STATE
ZIP CODE
Signed: __________________________________________________________________________________
Title: ____________________________________________________________________________________
Date: ____________
MEDICAL HISTORY AND PHYSICIAN’S REPORT
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Student Name: ___________________________________________________________________________
INFORMATION ON MENINGOCOCCAL MENINGITIS
Under the terms of the College and University Student Vaccination Act signed in June 2002, requires all
students living on campus 21 years or younger, to have documentation that they received a Meningococcal
Vaccine at 16 years or older or sign a waiver.
Meningococcal disease is a rare but potentially fatal bacterial infection of the membranes surrounding the brain
and spinal cord, or meningococcemia (bacteria in the blood). About 9-12% of people with this disease die even
with treatment, and those who recover may have serious after-effects like permanent hearing loss, limb loss, or
brain damage. Outbreaks are mostly due to Neisseria Meningitis which has risen on college campuses in recent
years. Research has shown that students residing in dormitories appear to be at higher risk than college students
overall, and freshmen living in dormitories have a six fold risk. Safe, effective vaccines are available to protect
against this serious disease. The vaccines provides protection against serogroups A,C,Y and W-135. The
duration of protection is about 3-5 years. Persons at risk should get the vaccine every 3-5 years.
For further information on this type of Meningococcal Meningitis please see www.vacineinformation.org;
www.immunize.org; www.cdc.org.
MENINGITIS WAIVER
DECLINE: I have reviewed information about Meningococcal Meningitis A, C, Y, and W-135, however I
decline the vaccine and voluntarily agree to release, discharge, indemnify, and hold harmless Saint Charles
Borromeo Seminary, its officers/employees from any costs, liabilities, expenses, claims, demands, or causes of
action on account of any loss, personal injury that might result from my not being vaccinated against this
disease. I am aware of the risks associated with Meningitis disease and the availability and effectiveness of
vaccines. I decline to be vaccinated for religious or other reasons.
If student is under the age of 18, parental signature is necessary
________________________________________
Student Signature
___________________________________________
Parent Signature
Date: ______________________
Date: ______________________
Insurance Information:
Plan: _______________________________________
Member Name ____________________________
ID# ________________________________________
Grp#: ____________________________________
Member Services Number _________________________________________________________________
MEDICAL HISTORY AND PHYSICIAN’S REPORT
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