Fillable Printable Student Medical Form - Carolina
Fillable Printable Student Medical Form - Carolina
Student Medical Form - Carolina
!!
Student Medical Form
Instructions for Completing Medical Form
DEADLINE'FOR'COMPLETED'MEDICAL'FORMS'AUGUST'1'
'$100'Late'Fee'
1
ͻϯDTP!(!Diphtheria,!Tetanus,!and!Pertussis)!Tdap!Booster!must!have!within
!!the!last!10!years.
ͻϮDDZ;DĞĂƐůĞƐ͕DƵŵpƐ͕ZƵďĞůůa).
!Physical!Exam!within!lasƚϭϮŵŽnths.
DĞĚŝcal!History!(completed!ďy!student).
Ϯ͘
remainder'of'the'form.'Make'sure'that'he/she:
ͻůů Ěates!must!include!month,!day!and!year.
ϯ͘Students'who'plan'to'play'intercollegiate'sports or attend Presbyterian School of Nursing!must!
send!this!completed!form!to!the!Health and Wellness Center in addition to any athletic or PSON
requirements.Our requirements are different and BOTH are necessary.
4.!
Services,'(704)'337S2220.
*All'records'must'be
legible'and'in'English.
please!return!to:
1900!Selwyn!ve.
͘DEdKZzƌĞƋƵŝƌĞŵĞŶƚƐĨŽƌĂůůŶĞǁƐƚƵĚĞŶƚƐ;&ƌĞƐŚŵĂŶ͕dƌĂŶƐĨĞƌƐĂŶĚ/ŶƚĞƌŶĂƟŽŶĂůͿ
dƵďĞƌĐƵůŝŶ^ŬŝŶdĞƐƚ;WWͿǁŝƚŚŝŶƚŚĞůĂƐƚLJĞĂƌ͘
Please'enclose'a'front'and'back'copy'of'your'insurance'card'when'you'submit'your'medical'form
Copy of Insurance Card OR
Taking the Queens United Healthcare Insurance Policy
Charlotte, NC 28274
Fax to:704-337-2333
OR E-mail to: [email protected]
!
1.
Student Medical Form (p. 2)
Report of Medical History
Last!Name!(print)! !!!First!Name!!!!!!!! !!!!Middle!Name!!!!!!!! !!!!!!!!!!!!!!!Social!Security!Number
Permanent!!Address!!!! !City!!! !!!!!!!!!!State!!!! !!!!!!!!!!!ZIP!
Student’s!Cell!Phone !!!Date!of!Birth!(mo/day/yr)!
Cell!phone (student) Student’s!Qmail Email address (please print)
Marital!Status!(circle!one):!!!!!!S!!!!!!!!!!!!!!!!M!!!! !Other!
Previously!Enrolled!Here!(circle!one):!!!!!!Yes!!!! !!!!!No! !Other!
Class!You!Are!Entering!:!!!!!FR!!!!!!!!!SO!!!! !JR!!!! !SR!!!!
Semest er!Entering:!!!!!! !Fall!!!!!!!Spring!!!Year!20_____!!!!
Please enclose a front and back copy of your insurance card when you submit your medical form.
Name!of!Person!to!Contact!in!Case!of!an!Emergency!!! !!!RelĂƟonship!!!!
Address!!!! Area!Code/Telephone!(Home)!!!! !!!!!Area!Code/Telephone!(Work)!
Area!Code/Telephone!(Cell)!!!! !Emergency!Contact!Email!
Family & Personal Health History
The!following!health!history!is!conĮdenƟal,!does!noƚĂīect!your!admission!status,!and,!except!in!an!emergency!situĂƟon!or!by!court!order,!will!not!be!
released!without!your!wriƩen!permission.!PleaseĂƩĂc h!addiƟonal!sheets!for!any!items!that!require!fuller!explanĂƟon. !
Has!any!person,!related!by!blood,!had!any!of!the!following:!
Yes! No! RelaƟonship!! Yes! No! RelaƟonship ! Yes! No! RelaƟon ship!
High!Blood!pressure! High!Cholesterol!! Blood!disorder!!
Stroke! Blood!fat!disorder! Alcohol/drug!problems!
Cancer!(type:!! !!)! Diabetes! Psychiatric!illness!
Heart!aƩack!before!age!55!
Glaucoma!
Suicide!
!!Have!you!ever!had!or!do!you!have!now:!(please check at right of each item and if yes, indicate year of rst occurrence)!
Yes! No! Year!! Yes! No! Year! Yes! No! Year! Yes!
No! Year!
High!Blood!press ure! Hay!Fever ! Hernia! Severe!menstrual!
cramps!!
RheumaƟc!Fever! Head!or!neck!radiaƟon!
treatments!
Anemia!or!Sickle!Cell!! Irregular!periods !
Heart!Trouble! ArthriƟs! Eye!trouble!besides!nee d!for!
glasses!
Blood!transfusio n!
Pain/pressure!in!chest! Concussion! Bone!or!joint!deformity! Smoke!1+!pack!
cigareƩes/week!
Shortness!of!breath! Frequent!or!severe!
headache!
Shoulder!dislocaƟon! Allergy!injecƟon!therapy!
Asthma!
Dizziness!or!fainƟng !spells!
Knee!problems! Alcohol/drug!abuse!
Pneumonia! Severe!head!injury! Recurrent!back!pain! Depression!
Chronic!cough! Paralysis ! Neck!Injury! Self`injury!
Tuberculosis! Epilepsy/Seizures! Back!injury ! Suicide!aƩempt!
Tumor!or!Cancer!
(specify)!
Ulcer!(stomach)! Broken!bones! LD/ADD/ADHD!
Malaria! IntesƟnal!trouble! Kidney!infec Ɵon! Bipolar!disorder!
Thyroid!trouble! Diabetes Bladder!infecƟon! Anxiety/panic!
Serious!skin!disease!
Frequent!VomiƟng!
Kidney!stone!
Sleep!problems!
Easy!faƟgability! Jaund ice!or!hepaƟƟs! Chickenpox(D isease)! EaƟng!disorder!
Sexually!transmiƩed!
illness!(STI)!
Rectal!Diseas e! Hearing!loss!
Mononucleosis! S evere!or!recurrent!
abdominal!pain!
SinusiƟs!!
IMPORTANT:!This!form!must!be!completed,!returned!to!the!HWC!and!found!complete
ďLJ^ƚƵĚĞŶƚ,ĞĂůƚŚΘtĞůůŶĞƐƐ^ĞƌǀŝĐĞƐ͘/ŶĨŽƌŵĂƟŽŶƐƵƉƉůŝĞĚǁŝůůďĞƵƐĞĚĂƐĂŶĂŝĚŝŶ
ƉƌŽǀŝĚŝŶŐŶĞĐĞƐƐĂƌLJĐĂƌĞǁŚŝůĞLJŽƵĂƌĞĂƐƚƵĚĞŶƚ͘dŚĞŝŶĨŽƌŵĂƟŽŶŝƐƐƚƌŝĐƚůLJĨŽƌƚŚĞ
use!of!Student!Health!and!Wellness!Services!and!will!not!be!released!to!anyone!
without!your!knowledge!and!consent.
!
Please!describe!any!cond ons!or!disabil s!that!would!exclude!par p on!in!physical!educa on:!
Do!you!exercise! three!or!more! mes!per!week?!(circle one) !Yes! !No!
!
Please!list!any!drugs,!medicines,!birth!control!pills,!vitamins!and!minerals!(prescrip o n!and!nonprescrip on)!you!use!and!
indicate!how!o
en!you!use!them.!
Name____________________!Use_______!Dosage!_______!!!Name____________________!Use_______!Dosage!_______!
Name____________________!Use_______!Dosage!_______!!!Name____________________!Use_______!Dosage!_______!
Name____________________!Use_______!Dosage!_______!!!Name____________________!Use_______!Dosage!_______!
!
Yes! No! Explan on!
Penicillin!
Sulfa!
Other!an bio cs!(name)!
Aspirin!
Codeine!or!other! pain!relievers!
Other!drugs,!medicines,!
chemicals!(specify)!
Insect!bites!
Food!allergi es!(name)!
! I!would!like!for!a!counselor!from!the!Health!&!Wellness!Center!to!contact!me!about!mental!health!resources!on!campus.!!
If!you!checked!the!box,!please!list!your!preferred!co ntact!method:!!Phone___________ ______________!!!Email_____________________________ !
!
STATEMENT!BY!STUDENT!(OR PARENT/GUARDIAN IF STUDENT UNDER AGE 18)!
(A)!I!have!personally!supplied!the!above!informa on!and!a est!that!it!is!true!and!complete!to!the!best!of!my!knowledge.!I!understand!that!the!informa on!is!strictly!
conĮden
al!and!will!not!be!released!to!anyone!without!my!wri en!consent,!unless!otherwise!permi ed!by!law.!If!I!should!be!ill!or!injured!and!unable!to!sign!the!
appropriate!forms,!I!hereby!give!my!permission!to!Student!Health!Services! to!release!informa
on!from!my!(son/daughter)’s!medical!records!to!a!physician,!hospital,!or!
other!medical!personnel!invol ved!in!providing!me!(him/her) with!emergenc y!treatment!and/or!medical!care.!(B)!I!hereby!authorize!any!medical!treatment!for!myself!(my
son/daughter) that!might!be!advised!or!recommended!by!the!providers!of! the!Student!Health!&!Wellness!Center.!(C)!I!am!aware!that!the!Health!&!Wellness!Center!charges!
for!some!services!and!I!will!be!billed!through!the!Business!Oĸce.!I!accept!p ersonal!responsibility!for!se
ling!the!account!with!the!cashier!and!for!payment!of!incurred!
charges.!I!am!responsible!for!Įling!outpa
ent!charges!with!insurance!and!acknowledge!that!my!responsibility!to!the!university!is!unaīected!by!the!existence!of!insurance!
coverage.!
Student Signature Date
Yes! No! Explan on!
Have!you!ever!been!a!pa ent!in!
any!type!of!hospital?!(Specify!
when,!where!and!why.)!
Has!your!academic!career!been!
interrupted!because!of!physical!or!
emo onal!problems?!
Have!you!ever!been!in!a!
residen al!program!for!substance!
or!mental!health!treatment?!
Other!than!a!rou ne!checkUup,!
have!you!seen!a!physician!or!
healthUcare!professional!in!the!
past!six!months?!
Have!you!ever!had!any!serious!
illness!or!injuries!other!than!thos e!
already!note d?!(Specify!when,!
where!and!give!detail s.)!
!
Parent/Guardian Signature (if student under 18)
Student Medical Form (p.3)
(Family & Personal Health History continued)
Student Name ____________________
Have you ever experienced adverse reactions (hypersensitivities, allergies, upset stomach, rash hives, etc.) to any of the following? If yes,
please explain fully the type of reaction, your age when the reaction occurred, and if the experience has occurred more than once.
!!
!
!
Student!Medical!Form!Checklist!
o Ensure!all!immuniz ons!are!listed!(according!to!NC!State!Law)
o
!Physician!completes!and!signs!physician!form
o Enclose!a!copy!of!the!front!and!back!of!insurance!card
(does!NOT!cons
tute!insurance!waiver).
o
Tuberculin!(PPD)!test!is!current!(within!12!months)
o Make!a!copy!for!your!records
!!!!!!!!!!!!!! ! ! !! ! ! ! ! !!!!!!!!!!!!
TO!THE!EXAMI NING!PHYSICIAN:!!Please!review!the!student’s!medical!history,!immuniza on!history,!proof!of!PPD,!and!then!complete!
the!examina on!and!general!comments!po on!of!this!form.!
Vaccine Series Date Series Date Series Date Booster Date Booster Date The North Carolina Immunization
Law requires that students
entering college present to the
school authorities immunization
certi
cation.
DTP!(Date of series R equired)! #1 #2 #3 #4 !
Tdap!(Booster within 10 years) ! Required
Polio,!oral!
Hepa s!B! (Required)!
Hepa s!A!(recommended)!
MMR!(Measles,!Mumps,!Rubella)! #1 Booster required: #2 !
Please note that if this
requirement is not met,
dismissal from school 30
days after registration is
mandatory under the
law.
Meningococcal!(recommended)!
Gardasil!–!HPV!Vaccine!(recommended)! #1 #2 #3
Tuberculin!(PPD)!test!! !!Da te!given!
(within 12 months) Date!rea d Results mm induration
Chest!xWray,!if!posi ve!PPD!! !!Date!
!!Results!
Treatment,!if!applicable!! !!Date!
Please Do Your Part to make
sure you have the minimum
immunization required before
sending in your form.
Notes:!
Height! Weight! BP! Pulse! Temp.!
Vision!!R!!20/! ! L!!20/! ! Corrected! Hearing!(Gross)!!!R! L!
Are!there!abnormali es!of!the!following!systems?!
System!
Yes! No! System!! Yes!! No!
1. Head,!Ears,!Nose,!Throat 9. Musculoskeletal
2. Eyes 10. Metabolic/Endocrine
3. Respiratory 11. Neuropsychiatric
4. Lympha c 12. Skin
5.!Cardiovascular
Describe fully.
6. Gastrointes nal
7. Hernia
8. Genitourinary
Phys vity?!!!!!!!!
!
!!!Unlimited!!
!
!!!Limited!
Explain :____________________________________ ____________________ ____________________ ______________________!
Is!this!student!now!u nder!treatment!for!an y!medical!or!emo
onal!cond ons?!!!!!!
!
!Yes! !
!
!No!
Explain :______________________________ ____________________ ________________________________________________
!
Name!of!Provider!(Print)! Date! Signature!of!Provider!
KĸĐĞ!Address! (o r!Oĸce!Stamp)! Area!code/KĸĐe!Telephone!
Student Medical Form (p.4)
Report of Health Evaluation
Last%Name%%%%%%%%%%%%%%%%%%%%%%%%%%%%%First%Name% %%%%%%%%%%%%%%%%MI Date%of%Birth%(mm/dd/yyyy)
General Comments (diagnosis, recommendation, etc.)
