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Towson University College of Health Professions Department of Occupational Therapy and Occupational Science Health Examination Form PART I: HEALTH HISTORY (To be completed by Patient) NAME:______________________________________ Towson Student ID ____________________________Date of Birth _____/_____/_____ I agree that this form may be released to the facilities accepting me for fieldwork placement. _____________________________________ Signature of Student ___________________ Date MEDICAL HISTORY: Check the box to indicate a present condition or significant past history of the following. For any positive answers, please provide details below: Elevated cholesterol Epilepsy/Seizures Frequent bronchitis Headaches/migraines Hearing loss Heart murmur Heart valve problem Hepatitis Hospitalizations (specify cause) Irritable bowel/colitis/Crohn’s Infectious Mono Anemia/Bleeding trait Anorexia/Bulimia Asthma/Allergies Back or joint injuries Cancer/leukemia/Hodgkins Chicken pox Chronic Indigestion/ulcer Concussion/head injury Diabetes/hypoglycemia Dizzy/fainting spells Elevated blood pressure Kidney infections/stone Other: __________________ Frequent bladder infections Menstural problems/endometriosis Positive PPD Test Rheumatoid arthritis Frequent Sinus Infections Sleep disorder Surgery (specify) Thyroid disorder Chronic tiredness/fatigue Undesired weight gain/loss DETAILS: ______________________________________________________________________________________________________________ ALLERGIES: (Check all that apply) SMOKING HISTORY: _______ Packs per day Sulfa drugs Aspirin Penicillin/ampicillin Foods Eggs Other drugs (list)_______________ ALCOHOL INTAKE: _______ Drinks per week MEDICATIONS: List all medications taken on a regular basis. Include birth control pills and non-prescriptions drugs, such as vitamin supplements and over the counter medications. DRUG DOSE _______________________________________________________________Reason______________________________________ _______________________________________________________________Reason______________________________________ _______________________________________________________________Reason______________________________________ PART II: IMMUNIZATION RECORD POLIO VACCINE (complete series): Date received: ____/____/________ ADULT TETANUS/DIPHTHERIA/PERTUSSIS (T-dap) Date received: ____/____/________ ***POSITIVE TITER RESULT REQUIRED ____________________ ***POSITIVE TITER RESULT REQUIRED ____________________ ***POSITIVE TITER RESULT REQUIRED ____________________ ***POSITIVE TITER RESULT REQUIRED ____________________ MEASLES DOSE 1 ___/___/_____ DOSE 2 ___/___/_____ MUMPS ___/___/_____ ___/___/_____ RUBELLA ___/___/_____ ___/___/_____ VARICELLA ___/___/_____ ___/___/_____ HEPATITIS B DOSE 1 DOSE 2 DOSE 3 ***POSITIVE TITER RESULT REQUIRED ______________/______________/_______________/_________________________ *** Attach copy of lab report - if titers results are negative you must get updated vaccines and then repeat the titer DECLINED HBV VACCINE MENOMUNE ___/___/_____ MENACTRA ___/___/_____ PART III: HEALTH ASSESSMENT (To be completed by Health Care provider) REVIEW of SYSTEMS: (List pertinent positives) HEENT _______________________________________ GU _______________________________________ C-V___________________________________________ ENDO_____________________________________ RESP__________________________________________ NEURO____________________________________ GI_____________________________________________ M-S_______________________________________ PHYSICAL EXAMINATION: B/P ______/______ R/L VISION: Corrected Uncorrected Far: R 20/______ L: 20/_______ WNL ABNL P: __________ WT: ___________ Describe N/A Gen./skin Breasts* Head/Neck Abdomen ENT Extremities Eyes Back/Spine Chest/Lungs Genitalia* Heart Hernia Neuro Rectal * HGT: _________ WNL ABNL Describe *Only if indicated by history LAB STUDIES: Mantoux 2-Step PPD Test: 1st PPD Date:_______________ *HGB/HCT: __________________ 2nd PPD Date:_______________ mm induration _____________ Second PPD must be done within 7-21 days of the first PPD to be considered a 2-step PPD OR *Urinalysis POS mm induration _____________ Tspot or Quantiferon Gold Blood Test: Date:______________ Results:___________________ NEG Nitrates *If test results are positive a Chest X-Ray is required* Chest x-ray ___ normal ___ abnormal (must attach written x-ray report) Leukocytes Albumin Glucose Blood If prior documented positive PPD (in USA), and written CXR report, a yearly "TB Symptom Free Evaluation" must be completed. Attach copy. Date completed___________________________________ Patient is free of communicable diseases: YES NO *ONLY IF INDICATED BY HISTORY Health Care Provider completing this form: _______________________________________ (please print) Signature: ______________________________________________ Date: _____________________________________ Address: ________________________________________________ Telephone: ________________________________ **HEALTH INSURANCE: A copy of your health insurance card is required annually for verification of insurance coverage
