Download AC Health Form 062112

Office of Community Life • One Morgan Place • Yellow Springs, OH 45387 • www.antiochcollege.org/campus_life
Antioch college health form
Please Note: this form is required before you can register for classes. This information is received by the
Community Life office and will be kept confidential. Email this completed form to [email protected] or via
postal mail to the address at bottom.
student information
Student name: First Middle
Last
date of birth
Gender Parent/guardian’s name
permanent street address City
Insurance Company Name State
zip
Policy #
Policy Holder’s Name
medical history
(To be completed by student)
Indicate with a check in the box if you have had one of the following conditions:
Allergies (Hay fever, sinus etc.)
Asthma
Bladder Infection/Disease
Diabetes
Dizziness/Fainting
Headaches/Migraines
Heart Murmur
High Blood Pressure
Infectious Mononucleosis
Kidney Infection/Disease
Seizures
Tuberculosis
List any of the following you may have had:
Serious injuries
Chronic/serious illnesses
Operations
List any medications you are now taking
Drug sensitivities/allergies
Have you ever had any of the following? If yes, briefly describe:
Psychological/ psychiatric treatment
Psychiatric hospitalizations
Alcohol or drug treatment
Any mental or physical health concerns not covered above (i.e., individualized education plan, documented learning disability)
Physician’s Exam
(To be completed in its entirety by a physician)
Note to Physician: This form must be completed in its entirety. Please review student’s history before completing
the physical examination.
Height
Weight Blood Pressure
/
Pulse
(minute)
Please indicate with a check mark if there are any abnormalities with the following and explain in the comments
section provided below:
Abdomen and viscera (include hernia)
Endocrine system
Eyes – general (lids, pupils, motions, etc.)
Genito-urinary system
Head, nose and sinuses Heart
Neurological system Respiratory
Skin and lymphatic (include acne)
Spine, other musculoskeletal
Vascular system (include varicosities)
Comments
Meningococcal and Hepatitis B Vaccination Status
Meningococcal vaccine received:
Yes
No
If yes, Dose Date /
/
Hepatitis B vaccine received:
Yes
No
If yes, Dose #1 Date /
/
Dose #2 Date /
/
Does # 3 Date /
/
/
/
Tetanus-Diptheria(td) or Diptheria-Pertussus-Tetanus(dpt) Vaccinations
(One of which must have been administered in the last ten years.)
Yes
No
If yes, Dose #1 Date Dose #2 Date /
/
Does # 3 Date /
/
/
/
/
/
Measles-Mumps-Rubella Vaccinations (MMR) (Two doses required, both after first birthday)
Yes
No
If yes, Dose #1 Date Check one: This student
MAY
Dose #2 Date MAY NOT engage strenuous physical activity.
Print Physician’s Name
Physician’s Signature
Office PhoneDate of Examination
Antioch College • Office of Community Life • One Morgan Place • Yellow Springs, OH 45387 • 937.471.0506 • antiochcollege.org/campus_life