Peace College Medical Form

8/3/2019 Peace College Medical Form

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Date of Birth (mo./day/year) Maritial Status _Single _Married

Yes/ No Yes/ No Yes/ No

Yes/No Yes/No Yes/No

Eye trouble besides

needing glasses

Bone, Joint or ther

deformity

Server ot Recurrent

abdominal pain

Have you ever had or have you now:

High Blood Presure

Peace College

Health Center

Raleigh,NC 27604

Phone:(919)508-2502 Fax:(919)508-2501

Home Address(Name and Street) City State Zip Code Area Code/Phone

Family & Personal History (please print in black ink) To be Completed by student

Has any person,related by blood, had any of the following:

Peace College Medical History Report(Please complete this side of the form before going to your physician for an examination )

Last Name(Please Print) First Name Middle Name Social Security Number

High Blood Preasure

(Please Print) - (Please Use the Space Below to explain the relation to the Health issues above)

Cholesterol/blood fat disorder

Diabetes

Glaucoma

Cancer(type)

Alcohol/Drug Problem

Suicide

Stroke

Heart Attack Before age 35

Hay Fever Jaundice or hepatitis

Rheumatic fever Allergy injection therapy Renall DiseaseHeart Trouble

Pain or Pressure in Chest

Shortness of Breath

Asthma

Pneumonia

Chronic cough

Tuberculosis

Head or neck radiation

Tumor or Cancer(specify)

Malaria

Thyroid trouble

Diabetes

Arthritis

Concussion

Frequent or servere headache

Dizziness or fainting spells

Servere head injury

Paralysis

Epilepsy/Seizures

Disabling depression

Excessive worry or anxiety

Ulcer(duodenal or stomach)

Intestinal trouble

Cyst

Hernia

Shoulder dislocations

Frequent Vomiting

Bladder infection

Easy fatigability

Anemia or sickle cell

anemia

Knee problems

Recurrent back pain

Neck injury

Please Indicate in the space below the health issue along with the year it first occurred:

Kidney infection

Chicken Pox


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Yes/No Yes/No Yes/No

Name Use Dosage

Name Use Dosage

Name Use Dosage

Name Use Dosage

Name Use Dosage

Name Use Dosage

Yes No

Have you every had a serious

illnessor injuries not noted

Other than for routine

checkups, have you seen

a physician or health care in the

past

6 months?

Have you ever been a

patient in any type of hospitla?

Explanation

Is there loss or seriouly

impaired function of any paired

organ?

Check each item"yes" or "no." Every item checked "yes" must fully be explained in the space give

Please list any drugs, medications, birth control pills, vitamins and minerals

(prescription or nonprescription) you use and indicate how often you use them.

Please list any food allergies and reactions:

Please list any known drugs or allergies and reactions:

Serious skin diseaseGall bladder trouble

or gallstones

Please Indicate in the space below the health issue along with the year it first occurred:

Alcohol use

Drug use

Anorexia/Bulimia

Personal Trauma

Irregular periods

Sexually transmitted disease Blood Transfusions

Smoke(#Cigarettes a day)

Family & Personal History-CONTINUED (please print in black ink) To be Completed by student

Back injury

Kidney stones

Protein or blood in urine

Broken bone(specify)

Mononucleosis

Hearing loss

Sinusitis Servere menstrual cramps


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Mo/Day/Yr Mo/Day/Yr Mo/Day/Yr Mo/Day/Yr

REQUIRED IMMUNIZATION RECORD

VACCINE

MUMPS: One dose required if born in 1957 or later.

If received before 1st birthday or 12/28/67, must

be repeated. Not required if entered 1st grade

before 7/1/87 or college before 7/1/94.

Alternate:Date of mumps

disease &signature of diagnosing

physician, or

serologic confirmation of immunity.

POLIO: Three oral doses required ONLY if

under the age of 18.

DTP. DT. or Td: Primary series of three doses of

which one dose must have been within the last

10 years.

RUBEOLA (Measles) : Two doses required if born

in 1957 or later. If received before 1st birthday or

3/21/63, must be repeated. Second dose not

required if enrolled before 7/1/94.

Alternate:Date of mumps

disease &signature of diagnosing

physician, orserologic confirmation of immunity.

RUBELLA (German Measles): One dose required

if under the age of 50. History of disease,vaccination

before 1st birthday, and vaccine before 6/9/69 not

acceptable. Not required if entered college after

30th birthday and before 2/1/89.

Alternate:Serologic

confirmation of immunity

Meningococcal Vaccine (Recommended)

Result:_____________mm.induration.

PPD (Mantoux) SKIN TEST: Must have been

tested within one year.

CHEST X-RAY: Required if skin test

was positive, or history of BCG or INH therapy. Attach copy of x-ray report

HEPATITIS B (Recommended)

Please give an recommendations regarding the care of this student or any general comments.


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Comments or Information from previous page:

PARENTS OF STUDENTS UNDER 18: I hearby authorize any medical treatment for my

daughter which may be advised or recommended by the medical staff of the Student Health

Services at Peace College.

Physician's Name (Print or Type)

Signature of Parent/ Gaurdian Date

Physician's Address Phone Number

Physician's Signature(acknowloging review of immunization) OR Health Department Stamp

Return completed form to:

Director of Student Health Services

Peace College

15 East Peace Street

Raleigh, NC 27604-1194

(919)508-2000


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Neuropsychiatric:

Skin:

Hernia:

Genitourinary:

Musculoskeletal:

Metabolic/Endocrine:

Glasses:

Cardiovascular or Respiratory:

Gastrointestinal:

Ears, Nose, Throat:

Head:

Eyes:

Hemoglobin/ Hematocrit:

Are there abnormalities

of these systems? Yes No Comments (Use additioal pages if needed)

Blood Pressure:

Urinalysis:

Height: Overweight / Underweight

Micro:

Vision:Normal:

Hearing(Gross)Rt/Lt:

Report of Physician's Examination

Pulse: Blood Type(Optional)

Albumin:

Weight:

Last Name (Print or Type) First Name Middle Name

Contacts:


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Peace College Medical Form

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