CSU IMM BAND STUDENT HEALTH RECORD
PART 1 - TO BE FILLED OUT BY THE STUDENT

Name DOB Email
Sex Female   Male   Phone # Cellular #
Present Address
Permanent Address


Medical History

1 Are there any restrictions to physical activity, please explain
2 Have you been treated by a physician or nurse practitioner in the past 5 yrs? For what reason ?
3 Have you ever been hospitalized ? If so, why?
4

Do you have Medical Insurance ? Company and policy #
5 Are you allergic to any medications or latex?
6 Give month and year of last vaccinations/inoculations
MMR: Tetanus or Td: PPD: Results: Neg. Pos.

Check all the following which apply to you and close relatives (parents, siblings, 1st grandparents)
Please indicate who:

You Relative
(ex: parents, siblings, grandparents)		 You Relative
(ex: parents, siblings, grandparents)
Allergies Headaches
Anemia Hepatitis
Asthma Hypertension
Cancer High Cholesterol
Cardiovascular Stomach/Bowel
Diabetes Kidney Disease
Drug & Alcohol Skin Disease
Mental Problems Thyroid Disease
Gallbladder/Liver Tuberculosis
Other, please explain
 

I certify to the best of my knowledge that the above information is complete and correct.
Applicant's Signature Date
       
AUTHORIZATION FOR MEDICAL, DENTAL, SURGICAL, OR OTHER TREATMENT
I hereby authorize and consent to deemed necessary or advisable services, including but not limited
to diagnostic procedures, radiology, laboratory, anesthesia, medical, surgical, dental, and or hospital
services.
Signature Date

 




PART 2 - TO BE COMPLETED BY A PHYSICIAN OR NURSE PRACTITIONER


Weight Height

BP

 Pulse
Vision Test ---- Urinalysis: Albumin Glucose
    Serum: Hemoglobin HCT
Is the applicant currently receiving treatment? If so, why?

 

CLINICAL EVALUATION

Check each item in the appropriate column Normal Abnormal If Abnormal, Describe
1. Skull, Scalp, Face, Neck, Thyroid
2. Skin, Lymphatic
3. Ears, Nose, Throat
4. Eyes
5. Neurological
6. Lungs and Chest
7. Heart
8. Abdomen
9. Perineum, rectum, hernias
10. Endocrine
11. Musculoskeletal
12. Psychiatric
Please indicate any medical condition which would interfere with regular physical activity.
Signature Date
Provider's Printed Name, Address, and Telephone Number of Provider

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