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Revised May 2007 Student Health Form PHYSICAL EXAMINATION (To be completed by medical provider) HEALTH FORM MUST BE COMPLETED AND RETURNED TO THE UNVERSITY’S HEALTH SERVICE CENTER PRIOR TO MOVING ON CAMPUS OR REGISTERING FOR CLASSES. MAILTO ADDRESS SHOWN AT THE BOTTOM OF PAGE 4 INSTRUCTIONS: 1. Complete Sections I and II by providing the requested information (all students 18 years of age and older). 2. If you are under 18 years of age, a parent or guardian MUST complete and sign Sections I and II. 3. Have any licensed medical provider fill out Section III including the required laboratory test. I. INFORMATION ____________________________________________________________________________________________________________________ LAST NAME FIRST NAME MIDDLE INITIAL DATE OF BIRTH SEX (mo / day / year) ____________________________________________________________________________________________________________________ RESIDENTIAL ADDRESS STREET RURAL ROUTE CITY ISLAND / STATE ____________________________________________________________________________________________________________________ MAILING ADDRESS (IF DIFFERENT FROM ABOVE) ZIP CODE ____________________________________________________________________________________________________________________ PARENT OR GUARDIAN NAME HOME PHONE BUSINESS PHONE ____________________________________________________________________________________________________________________ PARENT OR GUARDIAN RESIDENTIAL ADDRESS (IF DIFFERENT FROM ABOVE) STUDENT E-MAIL ADDRESS II. MEDICAL CONSENT (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 Service Center (personnel, medical providers and nurses, or the medical provider designated by the campus physician) and/or surgical treatment to: ______________________________________________________ NAME OF CANDIDATE FOR ADMISSION during her/his enrollment at the University of the Virgin Islands. I also grant permission for her/his hospitalization and treatment herein, 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 Service Center 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 DATE SIGNATURE OF STUDENT (IF OVER 18 YEARS OLD) (mo / day / year) PLEASE PRINT CLEARLY University of the Virgin Islands – Student Health Form 2 Last Name_______________________First Name____________________Initial______Sex______ DOB ____________ Mailing Address _______________________________________________ Phone _____________________ (H W C) City _____________________ State _____ Zip Code __________ University ID# __________________________ Employer______________________________ Occupation ___________________ Work Phone___________________ Emergency Contact Information Name_________________________________ Relationship_____________________ Phone _____________________ Address________________________________ City____________________________ State _____ Zip_____________ Patient Medical History Information YES NO DO YOU HAVE OR HAVE YOU EVER HAD: YES NO DO YOU HAVE OR HAVE YOU EVER HAD: COMMENTS (Office Use Only) 1. Eye trouble (exclude glasses, contact lenses) 31. Frequent or painful urination 2. ANY allergies: 32. Blood, protein, or sugar in urine 3. Take any medications regularly 33. History of diabetes 4. Frequent, severe, or migraine headaches 34. Kidney stone 5. Fainting or dizzy spells 35. Hernia or rupture 6. Periods of unconsciousness 36. Back pain or trouble 7. Head injury or skull fracture 37. Paralysis or weakness 8. Epilepsy, seizures or convulsions 38. Foot trouble / use orthotics 9. Loss of memory (amnesia) 39. Rheumatic fever 10. Depression, anxiety or nervousness 40. Any bone or joint problem or injuries 11. Any mental condition or illness 41. Tuberculosis or positive TB test 12. Hearing loss 42. Sexually transmitted disease (STD) 13. Ear, nose, or throat trouble 43. Any skin conditions 14. Sinusitis or sinus trouble 44. Adverse reactions to vaccines / drugs 15. Hay fever or allergic rhinitis 45. Adverse reactions to food / insect bites 16. Tooth/gum trouble or current orthodontics 46. Sensitivity to chemical, dust, sunlight, etc. 17. Thyroid trouble 47. Eating disorder 18. Chronic cough or lung disease 48. Recent gain or loss of weight 19. Asthma or wheezing 49. Excessive bleeding or easy bruising 20. Unusual shortness of breath 50. Tumor, growth, cyst, or cancer 21. Pain or pressure in chest 51. Considered or attempted suicide 22. Palpation or pounding heart 52. Learning disability or speech problems 23. High blood pressure 53. Had ANY surgery 24. Heart trouble or heart murmur 54. Any other injury or illness not noted above 25. Stomach, liver, or intestinal problem XXXX XXXX FEMALES ONLY 26. Gallbladder trouble or gallstones 55. Had a change in menstrual pattern 27. Hepatitis (yellow jaundice) 56. Been treated for a female disorder 28. Hemorrhoids or rectal disease 57. Experience painful periods or cramps 29. Black or bloody stools 58. Have you ever been pregnant 30. Constipation / Diarrhea 59. Are you currently pregnant I grant permission for the personnel of the UVI Health Service Center (HSC) to examine and treat me for the reasons I have presented. I agree to be responsible for all charges incurred. I hereby authorize my insurance benefits to be paid directly to UVI Health Service Center. I authorize the release of any information required to process any insurance claim or any report required by a municipality or governmental agency. I also agree to be responsible for payment of services including those not covered by my school insurance (students only) and/or insurance company, including; late fees and collection costs. _________________________________________________ ________________________ Signature (Parent/Guardian must sign if under 18 years old) Date (mo / day / year) III. PHYSICAL EXAMINATION (to be completed by a medical provider) University of the Virgin Islands – Student Health Form 3 Student Name ______________________________________ DOB _____/_____/_____ ____Female ____Male Height _________ Weight ________lbs Blood Pressure ______ /______ T ______ P ______ R ______ Distance Vision: Right uncorrected: 20 /____ Right corrected 20 / ____ Left uncorrected: 20 / ____ Left corrected 20 / ____ Color Vision: ____ normal ____abnormal Hearing (whispered voice at 10 feet): Right ____ heard ____ not heard Left ____ heard ____ not heard ALLERGIES: ____________________________________________ SYMPTOMS: __________________________ SYSTEMS NL ABNL NA Comments: HEENT HEART LUNGS ABDOMEN EXTREMITIES NEURO SKIN GENITAL (General PE Only) CURRENT MEDICATIONS: Name of Medication(s) Dosage How Often Discontinued 1. 2. 3. CURRENT TREATMENT(S): SURGICAL & PAST MEDICAL HISTORY: ADDENDUM: University of the Virgin Islands – Student Health Form 4 IMMUNIZATIONS: Polio: ____/____/____ ____/____/____ ____/____/____ ____/____/____ Tdap: ____/____/____ ____/____/____ ____/____/____ ____/____/____ ____/____/____ TD: ____/____/____ ____/____/____ ____/____/____ ____/____/____ MMR: ____/____/____ ____/____/____ Hepatitis B: ____/____/____ ____/____/____ ____/____/____ Meningococcal (one time dose for on campus residence ONLY): ____/____/____ Varicella: ____/____/____ ____/____/____  History of Disease Influenza (optional): ____/____/____ PPD: ____/____/____ PPD Reading: ____/____/____ ____ mm ____ Negative ____ Positive PPD: ____/____/____ PPD Reading: ____/____/____ ____ mm ____ Negative ____ Positive PPD: ____/____/____ PPD Reading: ____/____/____ ____ mm ____ Negative ____ Positive CXR Results (required for positive PPD): ___________  INH Treatment Received: ____ 3 months ____ 6 months ____ 9 months LABORATORY TEST RESULTS: CBC: _______________ UA: _______________ FBS: _______________  Lab Slip Given According to my review of systems, history and physical examination of the student: _____She/He is fit for any form of physical activity _____She/He should be excused from participation in strenuous physical activity _____She/He should be excused from participation in all forms of physical activity ______________________________________________________ _____________________________________________ MEDICAL PROVIDER NAME (Please Print) SPECIALITY AREA MEDICAL PROVIDER’S SIGNATURE: ______________________________________________________ DATE: ___________ (mo / day / year) MEDICAL PROVIDER’S ADDRESS: ______________________________________________________ ______________________________________________________ ______________________________________________________ UVI MEDICAL PROVIDER’S SIGNATURE: __________________________________________ DATE: ___________ (mo / day / year) UNIVERSITY OF THE VIRGIN ISLANDS St. Croix Campus St. Thomas Campus Health Service Center Health Service Center RR#1 Box 10, 000 Kingshill #2 John Brewers Bay St. Croix, VI 00850-9781 St. Thomas, VI 00802-9990 (340) 692-4208 (Office) (340) 693-1124 (Office) (340) 692-4225 (Fax) (340) 693-1211 (Fax)