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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