Health Services Office
MEDICAL EXAMINATION FORM
DATE: _________________
SCHOOL YEAR: __________

ID NUMBER: _____________________
COLLEGE: _____________
LAST NAME: _____________________
FIRST NAME: ______________________ M.I._______
CONTACT#: ________________
CONTACT PERSON IN CASE OF EMERGENCY: ________________________
RELATIONSHIP: ______________
CONTACT#: _________________
AUTHORITY TO CONDUCT MEDICAL EXAMINATION
I, __________________________, ____years old accept and understand that I am required to undergo a physical examination and chest x-ray to determine my fitness and well-being as a student. I fully understand that the results will be held as confidential medical records and will be used by the University for my care and treatment. My health information cannot be released to third persons except with my consent or unless the disclosure of the information is required by law. I also accept and understand that the procedures are requirements for the next academic year enrolment. I acknowledge that my medical records will be retained by the University for a period of 5 years from examination or health visit.

________________

Signature of Student
PHEX Consultation Details
Physical Exam (to be filled-out by a nurse/doctor)
Medical History (updated)
Blood Type_______________
1.__________________
_
Blood Pressure____________
2._______________________
Resp. Rate_______________
3._______________________
Temperature______________
4._______________________
Pulse Rate________________
Height (in inches) __________
Medications_______________
Weight (in pounds) ________
__________________________
BMI (to be computed by the system) _____ __________________________
BMI Category-system-generated_______
LMP (Female) ________
Social History
Right Vision__________
___ Smoking
Left Vision ___________
___ Drinking
___ Exercising
Corrective Lens
Findings
Extremities