Study Abroad Physical Exam, Consent, and Release Form (Page 1 of 8)
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1 Study Abroad Physical Exam, Consent, and Release Form (Page 1 of 8) In submission of this form, I acknowledge that New York University has no obligation to seek any medical treatment whatsoever on my behalf. Personal Information Male Female Date of Birth: Month/Day/Year Place of Birth Local Telephone Local Address City State Zip Code Country Family Information Father Telephone Mother Telephone Permanent Address City State Zip Code Country Emergency Contact Information of Person to Contact in an Emergency Relationship to Student Address City State Zip Code Country Telephone Cell Phone Work Telephone
2 (Page 2 of 8) To the Parents or Legal Guardian: If your son, daughter, or ward will be under the age of 18 years while on a New York University Study Abroad Program, it is our policy to secure your consent for medical treatment. By signing the consent form below, you will be giving your consent for any medical evaluation and treatment necessary to ensure the continued health of the student. In the event of a major health problem, whenever possible, specific permission will be obtained from you. Authorization for Treatment of a Minor I,, being parent or legal guardian of, give my consent to New York University Study Abroad, the physicians and other personnel utilized abroad, to administer such care, procedures, and treatment that is deemed necessary and in the best interest of the patient. As long as the medical or surgical treatment considered necessary in the situation is in accordance with the generally accepted standards of medical practice for the particular type of injury or illness involved, I impose no specific limitations or prohibitions regarding treatment other than those that follow (if none, so state):. I understand that this authorization is good until the time at which the minor mentioned above reaches his or her 18th birthday. In submission of this form, I acknowledge that New York University has no obligation to seek any medical treatment whatsoever on behalf of my child. Signature (parent or guardian) Date Address City State Zip Code Country Home Telephone Work Telephone
3 (Page 3 of 8) Medical History To be completed by physician Please check any of the conditions listed below that the patient has had or currently has Measles Ulcer disease Seizures Allergies Rheumatic fever Stomach problems Diabetes Cancer Mumps Irritable bowel Hepatitis A Tuberculosis German measles (rubella) Trouble seeing Hepatitis B Gallbladder problems Chicken pox Trouble hearing Hepatitis C High blood pressure Hay fever Migraines Dizzy spells Tension headaches Hives Bleeding problems Vaginal infections Heart murmur Arthritis Bruising problems Pelvic infection Heart disease Bladder problems Kidney problems Anorexia Asthma Bulimia Pneumonia Back trouble Stroke Thyroid disease Anemia Sickle cell disease Epilepsy Varicose veins Blood clots Breast lumps/tumors Convulsions Uterine fibroids Uterine tumor Uterine cyst Chlamydia Gonorrhea Mononucleosis Syphilis Herpes Discharge from the penis Discomfort when urinating Lumps or lesions on Pain in genitals genitals Other problems Does the patient have any disabilities? Students with disabilities who will be studying abroad should contact the Henry and Lucy Moses Center for Students with Disabilities ( voice and TTY) in order to discuss resources that might be required, to provide the necessary documentation, and to arrange for these services well before departure. Has the patient ever had surgery? If yes, please provide details: Has the patient ever been hospitalized? If yes, please provide details: Has the patient been treated for an emotional If yes, please provide details: or psychiatric condition? Students who are currently being treated for such a condition should speak with their mental health professional regarding their time abroad, including arranging for services during their time abroad prior to departure, as well as providing for any required medication. The Office of Global Education ( ) can provide assistance with referrals abroad. Date of the patient s last Dental Examination Eye Examination Physical Examination Gynecological Examination
4 (Page 4 of 8) Medications/Allergies Is the patient currently taking any medication, vitamins, over-the-counter medications, or other health supplements? If so, please list: Is the patient allergic to any medications? If yes, please provide details: Is the patient allergic to any food or other If yes, please provide details: items (e.g., bee stings, peanuts)? Other allergies? If yes, please provide details: Social History Does the patient smoke now? Has the patient smoked in the past? Does the patient consume alcohol? Has the patient consumed alcohol in the past? How many packs per day? for years How many packs per day? for years Nutrition Does the patient follow a special diet? If yes, please provide details: Has the patient ever experienced a medically If yes, please provide details: significant amount of weight change in a year? Family History To be filled out by student in conjunction with physician. Please check any of the following medical conditions that anyone in the patient s family has or has had in the past. Please include relationship to patient. Diabetes High cholesterol Hypertension Heart disease Sudden death Cancer Stroke Kidney disease Gastrointestinal disease Birth defect or hereditary disease Other
5 (Page 5 of 8) Immunization Please indicate which of the following immunizations the patient has received and the date. To be in compliance, students must have both items in section A or one each from sections B, C, and D. A. M.M.R. (measles, mumps, rubella) if given instead of individual immunization. Month/Day/Year First dose: immunized on or after first birthday and on or after January 1, Second dose: immunized 15 months after birth or later and at least 28 days after first dose. B. MEASLES (rubeola) Had the disease, confirmed by office record. Has report of adequate immune titer MUST SUBMIT COPY OF LAB REPORT. First dose: immunized on or after first birthday and on or after January 1, 1968; and second dose: immunized 15 months after birth or later and at least 28 days after first dose. C. MUMPS Had the disease, confirmed by office record. Has report of adequate immune titer MUST SUBMIT COPY OF LAB REPORT. First dose: immunized on or after first birthday and on or after January 1, D. RUBELLA (German measles) Has report of adequate immune titer MUST SUBMIT COPY OF LAB REPORT. First dose: immunized on or after first birthday and on or after January 1, E. MENINGOCOCCAL MENINGITIS To be filled out by student in conjunction with physician. Check one box. I have (for students under the age of 18: My child has): had the meningococcal immunization (MenomuneTM) within the past 10 years. read, read, or have had explained to me, the information regarding meningococcal meningitis disease. I (my child) will obtain immunization against meningococcal meningitis within 30 days from my health care provider or New York University s Student Health Center, Allergy and Immunology Services. read, or have had explained to me, the information regarding meningococcal meningitis disease. I understand the risks of not receiving the vaccine. I have decided that I (my child) will not obtain immunization against meningococcal meningitis disease. Signature (Student/Parent or Guardian) Month/Day/Year All students attending NYU Study Abroad, including visiting students, are required to meet New York State laws regarding immunizations and to ensure that the NYU Student Health Center has this information on file. Failure to do so will impede release of grades, financial aid, etc. F. OTHER IMMUNIZATIONS Tetanus Flu vaccine Yellow fever Polio Typhoid Hepatitis A Hepatitis B Pneumonia vaccine Rabies Other, please list type and date:
6 (Page 6 of 8) Review of Symptoms Check any of conditions listed below that the patient has or has had in the past. Please provide details as necessary. CONSTITUTIONAL SYMPTOMS (e.g., headaches, fatigue, fever) EYES (e.g., eye disease/injury, blurred or double vision) EARS/NOSE/MOUTH/THROAT (e.g., hearing loss/ringing, drainage, chronic sinus problems, bleeds, swollen glands) CARDIOVASCULAR (e.g., heart issues, chest pain, angina) RESPIRATORY (e.g., chronic/frequent cough, blood) GASTROINTESTINAL (e.g., frequent diarrhea, constipation, blood in stool, nausea, vomiting) GENITOURINARY (e.g., painful urination, blood in urine, burning on urination, kidney stones) MUSCULOSKELETAL (e.g., joint pain/weakness, cold extremities, difficulty walking) INTEGUMENTARY (SKIN) (e.g., rash; change in skin color, hair, or nails) BREAST DISEASE (e.g., abnormal mammogram, pain, lump, discharge) NEUROLOGICAL (e.g., headaches, convulsions, seizures, paralysis, head injury) PSYCHIATRIC (e.g., depression, insomnia, fainting, memory loss/confusion) ENDOCRINE (e.g. excessive thirst/urination, hormonal problems, temperature intolerance) HEMATOLOGIC/LYMPHATIC (e.g., slow to heal after cuts, anemia, phlebitis, bleeding or bruising tendency, past transfusion) ALLERGIC/IMMUNOLOGIC History of skin reaction or other reaction to Penicillin or other antibiotics Morphine, Demerol, or narcotics Novocain or anesthesia Aspirin or pain remedies Tetanus or similar vaccines Iodine, Merthiolate, or antiseptics Other drugs/medications:
7 (Page 7 of 8) Please indicate the last date each item was examined, inclusive of this physical if conducting a new one, and indicate any abnormal issues. Enter N.E. if not evaluated Date Normal Abnormal (Note: Describe every abnormality in detail. Enter pertinent item number before each comment.) 1. Head, face, neck, scalp 2. Nose, sinuses 3. Mouth, teeth, throat 4. Ears (including whispered voice test) 5. Eyes, pupils, muscles balance 6. Ophthalmoscopic 7. Neck and thyroid 8. Thorax, breasts 9. Lungs 10. Heart (murmur, etc.) 11. Abdomen (including hernial) 12. Anus and rectum 13. Endocrine system 14. GU system 15. Upper extremities 16. Lower extremities 17. Feet 18. Spine, other musculoskeleta 19. Neurologic 20. Psychiatric evaluation 21. Skin 22. Lymphatic system 23. Vascular system (varicosities, etc.) 24. Other Physical Examination Summary Blood Pressure: Pulse: Height: Weight: Blood Type: Vision: Corrected Uncorrected OD 20/ 20/ OS 20/ 20/
8 (Page 8 of 8) Based on your evaluation, does this student have a medical or psychiatric condition that could make study in a foreign country, including developing world countries, inadvisable? No Yes If yes, please provide details: Please Print Physician s Physician s Signature Telephone Date of Examination Address City State Zip Code Country
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Rockwood Natural Medicine Clinic 9755 N. 90 th St., Suite A-210 Scottsdale, Arizona 85258 480-767-7119 Date: Name: Age: Sex: M F Are you: Married Separated Divorced Widowed Single How did you hear about
GIDEON G. LEWIS, M.D.
GIDEON G. LEWIS, M.D. Date: LAST Name: FIRST Name: MIDDLE Initial: Address: City: State: Zip Code: Date of birth: / / Social Security #: - - Sex: M F Marital Status (Circle): Single Married Divorced Widowed
McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM
McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM Please complete this form and bring it with you to your appointment Appointment Date Appointment Time Name Referring Physician Date of Birth Please
GoPrivateMD General Information & History
Date: Date of Birth: Age: Sex: Male Female Address: City: State: Zip: Telephone: Email: PREFFERED PHARMACY NAME & LOCATION: PRIMARY PHYSICIAN: SPECIALISTS: INSURANCE GoPrivateMD will not bill your insurance.
PLAS/RECON SURGERY PATIENT HEALTH HISTORY
PLAS/RECON SURGERY PATIENT HEALTH HISTORY Chief Complaint - Please describe the problem that brings you into the office today: Allergies 1. Do you have any allergies? if so, please list To Medications?
MEDICAL HISTORY (To be filled in by patient)
MEDICAL HISTORY Reason for Visit or Chief Complaint: Referred By: Present Illness: (To be filled in by Physician) I. Have you had any reactions, allergies or bad effects from any of the following: Serum
Scottsdale Family Health
Please list pharmacy you would like us to use for your medications. Pharmacy Phone Number Fax Number Since your last visit: 1. Have you been diagnosed with any new medical conditions? Yes No If Yes (give
Name Age Date. Address Phone. Name of Physician. Address Street Address City State Zip Code
Name Age Date Address Phone What is the reason for your visit today? Where have you been receiving your medical care? Name of Physician Address Street Address City State Zip Code PAST MEDICAL HISTORY:
Margie Petersen Breast Center
Medical History Questionnaire Name: Sex: Female Male Last First Middle Date of Birth: Age: Birth Place: Mother s Birth Name: Social Security #: - - Marital Status: Single Married/Partnered (how long) Divorced
NEW PATIENT HISTORY AND PHYSICAL FORM
Temp: BP: Ht: P: WT: R: NEW PATIENT HISTORY AND PHYSICAL FORM Patient s Name: Age: Sex: Male Female CHIEF COMPLAINT: (why you are here today) History of Present Illness LOCATION of pain / problem? HOW
ANY FAMILY HISTORY OF ANEURYSM OR DVT?
NAME: D/O/B: DATE: MR# WHAT PROBLEM(S) BRINGS YOU HERE TODAY? WHO SENT YOU TO US? DOCTOR/OTHER WHICH DOCTOR? WHAT SURGERY HAVE YOU HAD AND WHEN? (LIST) 1. 2. 3. 4. 5. 6. 7. HOW MUCH ALCOHOL DO YOU DRINK
Pre-Matriculation Physical Evaluation Form for Category A
Pre-Matriculation Physical Evaluation Form for Category A January 1, 2017 Dear Doctor: Please complete the attached pre-matriculation physical evaluation and perform a physical examination for our incoming
Johns Hopkins Hospital Division of Gastroenterology Patient Questionnaire
Johns Hopkins Hospital Division of Gastroenterology Patient Questionnaire Please complete this questionnaire before your scheduled appointment and bring this form with you the day of your visit. Patient
Southwestern Community College Extension Education Fire & Rescue Training Programs Student Medical Form
Jerry Sutton Public Safety Training Center 225 Industrial Park Loop Franklin, NC 28734 (828) 306- -2428 www.southwesterncc.edu/content/public-safety-training Southwestern Community College Extension Education
DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N)
Medical History: Patient: DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N) List the names of prescription
N E W Y O R K M E D I C A L C O L L E G E A M E M B E R O F T H E T O U R O C O L L E G E A N D U N I V E R I S T Y S Y S T E M
N E W Y O R K M E D I C A L C O L L E G E A M E M B E R O F T H E T O U R O C O L L E G E A N D U N I V E R I S T Y S Y S T E M HEALTH SERVICES BASIC SCIENCES BUILDING VALHALLA, NEW YORK 10595 TEL 914-594-4234
VASCULAR SURGERY PATIENT HEALTH HISTORY
VASCULAR SURGERY PATIENT HEALTH HISTORY Chief Complaint - Please describe the problem that brings you into the office today: Allergies 1. Do you have any allergies? if so, please list To Medications? To
UCCM ANISHNAABE POLICE SERVICE EMPLOYMENT VISION REPORT
APPLICANT NAME: UCCM ANISHNAABE POLICE SERVICE EMPLOYMENT VISION REPORT REACTION ACCOM. LIGHT PUPILS EQUAL UNEQUAL FUNDI FIELDS OF VISION COLOUR (TEST USED) WITHOUT GLASSES NEAR FAR WITH GLASSES RIGHT
BROADWAY SPORTS & INTERNAL MEDICINE, P.S TH AVE NE SUITE 202 BELLEVUE, WA P: F:
BROADWAY SPORTS & INTERNAL MEDICINE, P.S. 1600 116 TH AVE NE SUITE 202 BELLEVUE, WA 98004 P: 206 215-2288 F:206 215-2289 MEDICAL HISTORY QUESTIONNAIRE Date Name Date of Birth HT WT Current Medical Complaints
WELCOME TO THE MILLER CHIROPRACTIC CLINIC
WELCOME TO THE MILLER CHIROPRACTIC CLINIC We are pleased that you have chosen to consult us regarding your health. In order to help us evaluate your condition thoroughly, please complete the following
PATIENT HISTORY FORM
Please bring completed history form to your scheduled appointment, if not completed this could delay your office visit. Thank you PATIENT HISTORY FORM Appointment Date Appointment Time Name Referring Physician
MEDICAL ASSESSMENT PART 1 - SOCIAL HISTORY
Smoking history Alcohol history Never Quit Never Quit PART 2 - MEDICAL HISTORY Date of last colonoscopy? Date of last mammogram? Date of last pap smear? Date of last flu vaccine? Date of last pneumonia