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PHYSICAL EXAMINATION HEALTH FORM MUST BE COMPLETED AND RETURNED TO THE UNVERSITY PRIOR TO MOVING ON CAMPUS OR REGISTRATION. Mail to: STUDENT HEALTH SERVICES; UNIVERSITY OF THE VIRGIN ISLANDS, ST. THOMAS, V.I. 00802 INSTRUCTIONS: 1. Complete section by providing the requested information. 2. If you are under 18 years of age, have your parent or guardian complete section II. 3. Have your family physician fill out section III performing the required laboratory test. 4. Have your family dentist fill out section IV Please be certain that ALL of the requested information has been supplied. An incomplete form will be returned to you and your admission to the University delayed. I. INFORMATION (to be completed by the candidate for admission) DATE:_______________________ SOC SEC #_____________________________________ LAST NAME FIRST NAME MIDDLE NAME DATE OF BIRTH SEX RESIDENTAL ADDRESS STREET RUAL ROUTE CITY ISLAND/STATE MAILING ADDRESS (IF DIFFERENT FROM ABOVE) ZIP CODE PARENTS OR GUARDIANS NAME HOME PHONE BUSINESS PHONE PARENTS OR GUARDINS RESIDENTIAL ADDRESS II. MEDICAL CONSENT FORM (to be completed by the parent or guardian) I, the undersigned (parent or guardian) do hereby grant permission to the University of the Virgin Islands Health Center (personnel university physicians and nurses, or the physician designated by the university physician) and/or the local hospital to administer any medical or surgical treatment to: NAME OF CANDIDATE FOR ADMISSON during his/her enrollment at the University of the Virgin Islands. I also grant permission for his/her hospitalization and treatment therein, if such hospitalization is necessary. I understood that in the event of a serious illness, accidental injury or need for surgery an attempt will be made by the university’s health services to contact me by telephone. If unable to contact me, needed emergency treatment may be given as necessary in the best interest of the student. SIGNATURE OF PARENT OR GUARDIAN SIGNATURE OF STUDENT (IF OVER 18) DATE III. PHYSICAL EXAMINATION (to be completed by physician) Candidate’s Height____________ Weight __________ Blood Pressure____________ Distant Vision: right 20 ___________ corrected 20 ____________ Left 20 ___________ corrected 20 ____________ Color Vision (circle one) Normal Abnormal Hearing (whispered voice at 10 feet) (circle one) RIGHT: HEARD: NOT HEARD LEFT: HEARD: NOT HEARD Please circle any abnormalities of the following: Skin Lymph nodes Head Nose & Sinus Eyes Lungs & Chest Heart Vascular system Spine Ears Endocrine System Extremities Feet Abdomen Neurological If any of the above have been circled, please give and explanation: __________________________________________________________ ________________________________________________________________________________________________________________ Has the candidate been treated, or is he being treated for any of the following: (circle) Tuberculosis Diabetes Kidney Disease Heart Condition Anemia Migraine Asthma Thyroid Epilepsy Rheumatic Fever If candidate is now receiving care for any of the above please state treatment given, including diet, therapy, and or medications:__________ ________________________________________________________________________________________________________________ Does the candidate have a history of injury or operation that may interfere with his course of study? (circle) Yes No. If “yes”, please explain: ________________________________________________________________________________________________________________ Does the candidate have a history of any drug sensitivities? (circle) Yes No. If “Yes”, please explain, and state counteracting medications found to be effective:____________________________________________________________________________________________________ ________________________________________________________________________________________________________________ According to my medical knowledge of the candidate: (check one) a._____ He/She is fit for any physical activity. b._____ He/She should be exempted from all strenuous physical activity. c._____ He/She should be exempted from all physical activity. If “b” or “c” is checked, for how long a period?___________________________________ Has the candidate received any psychotherapy or been confined to a hospital for mental or emotional problems? (circle) Yes No. If “yes” explain: ________________________________________________________________________________________________________ Required Immunizations: Type: Poliomyelitis_______________________________________ Date:__________________ Tetanus-Series or Booster____________________________ Date:__________________ Tuberculin Test_____________________________________ Date:__________________ Negative Positive (If possible chest X-ray required) First Second Mumps: ____________________________________________________ Measles: ___________________________________________________ Rubella: ___________________________________________________ Required Laboratory Test: Hemoglobin ___________ Blood Type_________________ Serology (circle one) Negative Positive Urinalysis Sugar____________ Albumin __________________ Stool for parasites (circle one) Negative Positive If stool and/or blood examination was positive, have measures been taken to correct this? ________________________________________ ________________________________________________________________________________________________________________ Physician’s Signature:____________________________________ Degree__________________________ Physician’s Address:_______________________________________ Date____________________________ ATTENTION: AN ORIGINAL IMMUNIZATION RECORD AND ONE COPY MUST BE PROVIVED WITH THIS FORM. THE ORIGNAL RECORD WILL BE RETURNED TO YOU. IV. DENTAL EXAMINATION (to be completed by dentist) A dental examination has been given this candidate and any corrective procedures necessary have been completed. Dentist’s Signature:_______________________________ Dentist Address:__________________________________________________ Date:________________________________________