Fillable Printable Student Medical Form - Florida

Student Medical Form - Florida

German Measles (Rubella)

MEDICAL FORM

Please complete both sides no later than August 1 and return to: Florida Southern College

Student Health Center

111 Lake Hollingsworth Dr.

Lakeland, FL 33801-5698

1. Name (Last) (First) (Middle) 2. Date of Birth 3. Sex 4. Phone

5. Home Address (Street) (City) (State) (Zip) 6. Student Cell Phone

7. Social Security Number 8. Entrance Date 9.

10. Name of Parent or Guardian (please print)

I authorize medical treatment for myself by the Health

Services of FSC. (If student is under the age of 18,

parental permission is given for medical treatment.)

Please print in ink or type

12. Medical History (note in detail any signicant history) Use reverse side if needed.

Hepatitis B #1 #2 #3

Required For Resident Students and Suggested For Commuting Students

13. Blood Pressure

11. Give Dates IMMUNIZATION RECORD - Required

18. Clinical Evaluation (check each item in the appropriate column) N = normal A = abnormal

1. Nutritional

2. Skin/Nails

3. Head/Face

4. Eyes/Vision

5. Ears/Hearing

6. Nose/Sinuses

7. Mouth/Throat

8. Lymph Nodes

9. Heart

10. Lungs

11. Breasts

12. Abdomen

13. Vascular System

14. Endocrine

15. Neurologic

16. Spine

17. Upper Extremities

18. Lower Extremities

19. Geritourinary

20. Rectum

21. Psychological

N A

q q

N A

q q

19. Describe every abnormality in detail (use reverse side if necessary).

20. Describe any current treatment - please include all medications

21. Physical Restrictions or Limitations

Date

Phone Address (Street) (City) (State) (Zip)

Printed Name of Physician

Signature

17. Drug Sensitivity16. Weight 15. Height

14. Pulse

Other

Meningitis

Last Tetanus Booster

Polio

Mumps

DPT

Measles (Rubeola)

N A

q q

Parent/Student Signature:

I have read the information on meningitis and hepatitis B that the college provided.

I have received the vaccine on the following dates:

Meningitis vaccine:

(REQUIRED FOR ALL RESIDENTIAL STUDENTS)

Hepatitis B vaccine #1: #2 #3

I have elected to waive obtaining the following:

Hepatitis B vaccines

Meningitis vaccine

(THIS OPTION IS AVAILABLE ONLY TO COMMUTING STUDENTS)

Student signature Date

Parent signature if student Date

is under 18 years of age

Additional Space for Medical Form Data

MENINGITIS AND HEPATITIS FORM

Name SS# Date / /

Birth Date / / Sex M F Height Wt. Marital Status S M D W

Local Address Phone ( )

Permanent Address Phone ( )

To be completed by student PAST MEDICAL HISTORY Please print in ink or type.

Mark “X” if

you have had

Alcohol/drug dependence Heart problems

Allergy/hay fever Hemorrhoids

Anemia/blood disease Hepatitis

Anxiety High Blood Pressure

Arthritis/joint pain High cholesterol

Asthma Hypoglycemia

Back problem Insomnia

Bladder/kidney Liver disease/jaundice

Blood in stool Malaria

Cancer/cyst/tumor Mononucleosis

Clot in veins Pregnancy

Constipation Psychological problem

Depression Respiratory problem

Diabetes (sugar) Rheumatic fever

Diarrhea Sexually transmitted disease

Dizziness/fainting Shortness of breath

Ear & nose problem Skin problem

Epilespy/seizures Strep throat

Eye problem Swollen glands

Gallbladder/intestinal Swollen joints

Head injury Thyroid disease

Surgeries/hospitalization/injuries, list below: Tuberculosis

Ulcer

Varicose veins

Weight problem

Other:

Do you smoke? Yes No

How much per day?

Do you drink alcohol or use marijuana? Yes No Do you have any allergies to medication? Yes No

How much per day? If yes, please list:

Current medications:

Do you have any other allergies? Yes No

If yes , please list: