Illinois State University. Athletic Training Education Program
|
|
|
- Valerie Townsend
- 5 years ago
- Views:
Transcription
1 Illinois State University Athletic Training Education Program Procedures for Determining that the Health Status of an Athletic Training Student will permit him or her to meet the Established Technical Standards of the Program As an athletic training student, you will be providing athletic training services at a variety of clinical sites. The Athletic Training Education Program at Illinois State University has developed guidelines to safeguard the well-being of the athletic training students and the athletes in compliance with the Joint Review Committee on Educational Programs in Athletic Training. 1. Upon acceptance into the Clinical Instruction Practicum of the Athletic Training Education Program, all newly admitted students are required to complete and submit a physical examination performed by a licensed physician. As a portion of this physical examination, the physician must complete the accompanying document to verify vaccination records and the ability of the student to pursue unrestricted performance of athletic training skills and responsibilities or to identify conditions that would place the student at increased risk of injury or illness. The physical examination may be completed by your own personal physician or by University Health Services at Illinois State University. a. Students must comply with the University Health Services Policy on required immunizations and screenings. This should include a tuberculin (TB) skin test. In addition, vaccinations against Hepatitis B (HBV) and tetanus are strongly advised as is the varicella vaccine against chicken pox for those who have not had the disease. b. Athletic training students should be physically capable of performing cardiopulmonary resuscitation (CPR) and basic emergency care procedures. c. Athletic trainers frequently lift and carry loads (coolers, ice chests, spine boards) in the performance of their duties. Students with medical conditions which contraindicate or restrict these activities should notify the athletic training program director. The program director will work with the athletic training student and his or her physician to establish a reasonable, medically prudent plan to protect the health of the student. The athletic training program director will be responsible for advising the clinical instructors and supervisors regarding medically imposed limitations related to the student s performance of restricted athletic training related duties. Illinois State University does not discriminate against persons with disabilities in its admissions process or the selective admissions process for individual programs. Students with documented disabilities who anticipate special needs with any aspect of the athletic training education program including the clinical instruction practicum are urged to contact the Office for Disability Concerns. The faculty of the athletic training program will cooperate with the Office for Disability Concerns to make reasonable accommodations for students with documented disabilities admitted to the program. The attached form, the medical history form, and the physical examination form are to be completed by the attending physician who completes the physical examination on behalf of the student. Page 1 of 5
2 Technical Standards to be Completed by Attending Physician I completed a physical health examination of Printed name of examining physician on. Printed name of athletic training student Date I. Based upon my examination and the student athletic trainer s record of immunizations: This athletic training student is current on required immunizations. This athletic training student is NOT current on required immunizations. II. Based upon my examination today and the TB skin test, the athletic training student is free of communicable diseases: Yes, this is true No; further testing is advised III. Based upon my examination of this individual: This student is physically capable of completing the duties of an athletic training student with no identifiable restrictions. This student is physically capable of rendering CPR and emergency care procedures but should observe the restrictions noted below while performing the remaining duties of an athletic training student. (attach additional pages if necessary) This student is physically incapable of rendering CPR and emergency care procedures due to a medical condition. Signature of Examining Physician Page 2 of 5
3 Illinois State University Athletic Training Education Program Athletic Training Student Medical History and Physical Health Appraisal Form Name Date of Exam Date of Birth Age Sex To be completed by student: Briefly explain yes answers on accompanying sheet 1. Yes No Have you ever been hospitalized? 2. Yes No Have you ever had surgery? 3. Yes No Are you presently taking any medications? 4. Yes No Do you have any known allergies? 5. Yes No Have you ever had a seizure? 6. When was the date of your last tetanus shot? 7. Have you ever had: Mononucleosis Hepatitis Tuberculosis Rheumatic Fever Migraines Diabetes Asthma Ulcers Hernia Anemia Other acute or chronic illnesses not otherwise listed: 8. Yes No Have you ever had a neck injury that persisted a week or more? 9. Yes No Have you ever had a shoulder sprain, separation, dislocation? 10. Yes No Have you ever had a wrist sprain, fracture, or other problem? 11. Yes No Have you ever had a back injury or do you suffer from recurrent back pain? 12. Yes No Have you ever had a knee sprain or knee surgery? Any other orthopedic condition not previously mentioned? Student Signature Date Page 3 of 5
4 To be completed by attending physician or qualified health care provider: Height Weight BP Resting Pulse TB Skin Test Performed on: TB Results: Observed on: Clinical Assessment: Eyes Normal Abnormal Notes Ears Nose & Throat/Oral Chest Heart Abdomen Skin Males Only: Hernia Check: Negative: Positive: Page 4 of 5
5 Orthopedic Assessment: (gross abnormalities or previous history noted) Cervical Normal Abnormal Notes Shoulders Elbow Wrist/Hand Back Hips Knees Ankle/Foot General Comments: Physician Signature Date Thank you for your assistance in assessing this student for the Illinois State University Athletic Training Education Program. Page 5 of 5
Certificate of Health Examination and Immunity
AURORA UNIVERSITY and GEORGE WILLIAMS COLLEGE of AURORA UNIVERSITY School of Nursing Certificate of Health Examination and Immunity Student to complete pages 1-3 Name: Date of Birth: / / Sex: M F SS#:
Immunization Packet for Incoming Students
Health Occupations Division (707) 256-7600 Immunization Packet for Incoming Students Congratulations on being accepted into a Napa Valley College Health Occupations Program. This packet has been designed
Part I: Health Form. This form is to be completed by the incoming student by July 15. Name: Date of Birth:
Part I: Health Form This form is to be completed by the incoming student by July 15. Name: Date of Birth: Last First Middle MM/DD/YYYY Social Security #: Marital Status: ( ) Single ( ) Married ( ) Divorced
Student Health Record
LAWRENCE MEMORIAL/REGIS COLLEGE NURSING & RADIOGRAPHY PROGRAMS Student Health Record All three parts of this record must be complete. Health Records must be uploaded to the Castle Branch website at https://mycb.castlebranch.com
Vassar College 124 Raymond Avenue Box 17 Poughkeepsie New York Please contact us at for any questions/concerns.
Vassar College 124 Raymond Avenue Box 17 Poughkeepsie New York 12604 Please contact us at health@vassar.edu for any questions/concerns. This form must be submitted directly to the Health Service by July
Student Health Record
LAWRENCE MEMORIAL/REGIS COLLEGE NURSING AND RADIOGRAPHY PROGRAMS Student Health Record All three parts of this record must be complete. Health Records must be uploaded to the Castle Branch website at https://mycb.castlebranch.com
WELLNESS CENTER Student Health Services (434) FAX (434)
Page 1 WELLNESS CENTER Student Health Services (434) 223-6167 FAX (434) 223-7071 New Student Health Form The staff at Student Health are dedicated to providing you with high-quality health care designed
Did you complete the Sports Ware Online required information (
Dear New VSU Student Athlete and Parent/Guardian, Welcome to Virginia State University. It is important that a safe and knowledgeable environment is maintained for you, the student-athlete, the athletic
Jones Co. Jr. College Sports Medicine Medical History Questionairre
Jones Co. Jr. College Sports Medicine Medical History Questionairre DEMOGRAPHIC INFORMATION Full Name: Social Security #: - - Date of Birth: Sport: Year in School: Home Phone #: Cell Phone #: Parent/Guardian
have completed a physical exam on Print Physicians Name on. Name of Patient
This form must be filled out by the physician that completed the physical and returned to the ATP Director by the patient. This form will be kept on record in the students permanent program file. Please
Pre-participation Physical Examinations
Pre-participation Physical Examinations www.acsm.org Past Medical History History of any of the following should be made available to the healthcare provider: allergy allergies to medications asthma birth
PRE-ENTRANCE MEDICAL RECORD PART I: GENERAL INFORMATION-
The Medical Record MUST be completed and returned to the Program Coordinator or Compliance Coordinator PRIOR to starting clinical. The physical needs to be completed within 1 year of starting the program.
Dear Incoming Student:
Dear Incoming Student: As the Director of Wellness Services, I want to welcome you to Nyack College! Our Staff is dedicated to providing you with quality health care. Our philosophy is based on the wellness
Name Age Birthday / / Sex Last First MI. Home Address Street Apt City State Zip Code Home phone: ( ) Cell phone: ( ) Name of parent(s) or guardian:
I. HEALTH HISTY- To be completed by the STUDENT (Required of all full-time students) Please answer all questions. Information requested in this form is strictly for the use of the Health Center in providing
PATIENT INFORMATION. First
GUIDE DOGS OF AMERICA General Physician s Report This General Physician s Report is being requested in connection with an application for a guide dog. We require a recent physical exam and complete medical
Student Full Name: Date of Birth:
Student Medical Form This form is to be completed for new students upon admission, and returning students prior to starting grades 3, 6, and 9. Students participating in athletics must complete form every
CONTENTS ALL PARTS OF THIS PACKET ARE IMPORTANT, AND IT MUST BE COMPLETED IN ITS ENTIRETY!
2017-18 Point Park University Athletics Medical Packet Enclosed you will find many of the necessary forms needed to compete in intercollegiate athletics during the 2017-18 year. Please return all completed
Instructions for providing the required cadet physical and immunization forms.
Instructions for providing the required cadet physical and immunization forms. May 2012 All Incoming Cadets and Parents All incoming resident students (cadets) for the Milledgeville campus are required
Radford University School of Nursing GRADUATE HEALTH RECORD FORM
Revised 6/2018 Radford University School of Nursing GRADUATE HEALTH RECORD FORM The School of Nursing requires a complete Health Record and Certificate of Immunization be completed and signed by a licensed
Student Health Information
Student Health Infmation Vassar College This fm must be submitted directly to the Health Service by mail, email, fax by July 1. Please complete all sections. Please do not separate the sections. Incomplete
STUDENT HEALTH SERVICES 204 College Rd, Hampden-Sydney, VA 23943
Page 1 STUDENT HEALTH SERVICES 204 College Rd, Hampden-Sydney, VA 23943 NEW STUDENT HEALTH FORM The staff at Student Health are dedicated to providing you with high-quality health care designed specifically
EMS Education. Immunization/Physical Policy 2016
EMS Education Immunization/Physical Policy 2016 Immunizations: Students are required to have successfully completed immunizations or immunization series, as recommended by the Centers for Disease Control
Student Health Services
MEDICAL RECDS of birth Home address City State ZIP Home phone number Gender identity: Pronouns: Chosen Name Class status (circle): First year Sophomore Junior Senior Graduate Postbac Premed IN CASE OF
APPLICATION PACK CHECKLIST
APPLICATION PACK CHECKLIST Instructions Please tick if the relevant section is completed and included: Employment Application WorkCover Declaration Immunisation Record Form Record of Vaccinations Received
UNION MINE HIGH SCHOOL
UNION MINE HIGH SCHOOL Home of the DIAMONDBACKS umhs.eduhsd.k12.ca.us (select Athletics) Principal: Paul Neville Athletic Director: Jay Aliff FALL WINTER SPRING August 7, 2017 November 6, 2017 February
Dear New WUSM Student:
Dear New WUSM Student: Congratulations on your acceptance! We look forward to meeting you and working with you to achieve optimal health as you pursue academic success. Our mission at Student Health Service
Durham Public Schools Assumptions of Risk/Medical Treatment Release
Durham Public Schools Assumptions of Risk/Medical Treatment Release Student Athlete Name School Sport(s) Date The Durham Public Schools system makes every effort to prevent injuries, but injuries do occur
Program or Major Code: Current address: Blazer ID: Local Address: Permanent Address
UAB Student Health and Wellness Health History Form Learning Resource Center 1714 9 th Avenue South, 3 rd Floor Birmingham, Alabama 35294-1270 (205) 934-3580 Please save this form and upload it to CertifiedProfile.com.
Required Health Records for all Students
Required Health Records for all Students Failure to complete all required forms and immunizations will prohibit you from registering for classes or attending clinical rotation Health Records Specialist
Arcana Center for Integrative Medicine
Arcana Center for Integrative Medicine Patient s Name: Date of Birth: Reason for today s visit: Past Medical History Primary care physician: Date of last exam: (sick or well) Physician s Address: Office
Signature of student Date Signature of parent or guardian (if student is a minor) Date
Frances M. Maguire School of Nursing and Health Professions MEDICAL HISTORY/PHYSICAL EXAMINATION RECORD This form and requirements must be completed between July 1, 2014 and August 22, 2015 Please read
EL CENTRO COLLEGE CENTER FOR ALLIED HEALTH AND NURSING HEALTH OCCUPATIONS ADMISSIONS
EL CENTRO COLLEGE CENTER FOR ALLIED HEALTH AND NURSING HEALTH OCCUPATIONS ADMISSIONS PHYSICAL EXAMINATION AND IMMUNIZATION REQUIREMENTS In order to comply with the Texas Administrative Code (Title 25 Health
Student Health Center Phone: Fax:
Dear Perspective Student: On behalf of the Health Services team we would like to welcome you to Livingstone College. This letter is an aid to help you get your health records completed and turned in 30
Your completed Health Record and any laboratory results must be uploaded to the Student Health Portal at: shac.usciences.edu
Box 23; 600 South 43rd Street; Philadelphia PA 19104 Phone: (215) 596-8980 2017-2018 STUDENT HEALTH RECORD SUMMER/FALL 2017 DUE DATE: AUGUST 4, 2017 Your Student Health Record is to be completed and submitted
Name: New York Medical College A MEMBER OF THE TOURO COLLEGE AND UNIVERSITY SYSTEM. HEALTH SERVICES HISTORY and PHYSICAL
Name: New York Medical College A MEMBER OF THE TOURO COLLEGE AND UNIVERSITY SYSTEM HEALTH SERVICES HISTORY and PHYSICAL GENERAL INFORMATION Last Name First Name Date of Birth Age Sex (M,F) Marital Status
Student Health Services Office 5400 Ramsey Street Fayetteville, North Carolina Phone: (910) or (910) FAX: (910)
1 Last Name: First Name: MU Student ID#: Student Phone #: Year Attending: Fall Spring Year Attended if Returning Student Student Athlete: y/n Sport: International Student: y/n Physician Assistant Student:
Mount Mystics MSVU Athletics & Recreation
Mount Mystics 2015-2016 MSVU Athletics & Recreation Student Athlete Medical History Card Please complete the first 3 pages and bring to entire document to the doctor s office. Athlete Information Sport:
5. Statement of Applicant Health
5. Statement of Applicant Health Applicant Name: Date of Examination: Height: Weight: Blood Type (If known): Physician must answer each of the following questions. To be completed by attending physician.
GEORGE WASHINGTON UNIVERSITY HOSPITAL EMPLOYEE HEALTH SERVICES REQUIREMENTS FOR CLEARANCE:
GEORGE WASHINGTON UNIVERSITY HOSPITAL EMPLOYEE HEALTH SERVICES Office: 202 715 4275 Fax: 202 715 4587 Email: gwuehs@medcor.com Walk-in hours: M-F 8am-12pm and 1pm-4pm REQUIREMENTS FOR CLEARANCE: Physical
Keiser University Health Forms. Student Name: D.O.B. / /
These forms must be returned to Sentry MD. DO NOT RETURN THESE FORMS TO KEISER UNIVERSITY. Please return forms to Sentry MD, by emailing them as ONE PDF ATTACHMENT to Keiser@SentryMD.com or fax to 817-251-9593
Institute for Continuing Theological Education Pontifical North American College
Institute for Continuing Theological Education Pontifical North American College 00120 Vatican City State Europe Medical History and Physician s Report (Applicant completes pages 1-to-3 before taking this
Wisconsin Indianhead Technical College Allied Health and Nursing Divisions Health Form
Wisconsin Indianhead Technical College Allied Health and Nursing Divisions Health Form Student Name: Please check appropriate program: Nursing-Associate Degree (due ) Dental Assistant (due the first day
UWSP Medical History Form
UWSP Medical History Form 2017-2018 Student: Please complete the first 6 pages prior to your appointment with your medical provider. The medical provider must sign off on the medical history form. Student
SPOKANE COMMUNITY COLLEGE HEALTH SCIENCE PROGRAMS 1810 N GREENE STREET, MS 2090 SPOKANE WA PHYSICAL EXAMINATION (Student completes this side)
SPOKANE COMMUNITY COLLEGE HEALTH SCIENCE PROGRAMS 1810 N GREENE STREET, MS 2090 SPOKANE WA 99217 PHYSICAL EXAMINATION (Student completes this side) Name: Program: Address: Date of Birth: Day Phone: Evening
Pre-participation Physical Evaluation
Pre-participation Physical Evaluation HISTORY FORM Date of Exam: Name Sex Age Date of Birth Grade School Sport(s) Address Phone Personal Physician In case of emergency, contact: Relationship Phone (H)
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
The Lorelton Assisted Living
The Lorelton Assisted Living MEDICAL INFORMATION REPORT (To be completed by Applicant s Physician) has expressed interest in residing at The Lorelton. A requirement for admission is the completion of this
STUDENT ENROLLMENT FORM
Enroll Date: For Office Use Only Proofs of Residence Immunization: Y or N Birth Certificate: Y or N Other: Student ID#: Greenville, NY 12083 Home School ES MS HS Restrictions: STUDENT ENROLLMENT FORM The
PATIENT INFORMATION FORM (WOMEN ONLY)
PATIENT INFORMATION FORM (WOMEN ONLY) Name: Age: Sex: Birthdate: / / SS # A. Describe briefly your present symptom(s) or the reason(s) for seeing the doctor today: B. Name all illnesses or conditions for
International School Bangkok Physical Examination Report (New Student)
Physical Examination Report (New Student) A registered Medical Practitioner must complete this form. The examination should be completed no more than 6 months prior to commencement at ISB and submitted
Admission Medical Information Form
Return Form to: Admission Medical Information Form Part I: To Be Completed by Family or Staff of Birth: Sex: M F Race: Marital Status: Home Address: Phone Number: Number/Street City State Zip Last Time
Patient Profile. Full Name: Address: Work Phone: Date of Birth: Social Security #: (Circle One) Full Time / Part Time. Emergency Contact: Number:
Patient Profile Full Name: Address: City: State: Zip Code: Home Phone: Cell Phone: Work Phone: Date of Birth: Social Security #: Email Address: Employer: (Circle One) Full Time / Part Time Emergency Contact:
MEDICAL HISTORY AND EXAMINATION FORM INSTRUCTIONS
FULBRIGHT PROGRAM APPLICATION FOR STUDY IN THE UNITED STATES AND FOR A FELLOWSHIP, SCHOLARSHIP, ASSISTANTSHIP OR OTHER EDUCATIONAL GRANT MEDICAL HISTORY AND EXAMINATION FORM INSTRUCTIONS Having been selected
NORTH CAROLINA HIGH SCHOOL ATHLETIC ASSOCIATION SPORT PREPARTICIPATION EXAMINATION FORM
NORTH CAROLINA HIGH SCHOOL ATHLETIC ASSOCIATION SPORT PREPARTICIPATION EXAMINATION FORM Patient s Name: Age: This is a screening examination for participation in sports. This does not substitute for a
Course Sequencing & Descriptions
Department of Kinesiology Athletic Training Major Course Sequencing & Descriptions All courses require a grade of C or better for completion PRE-PROFESSIONAL PHASE: SOPHOMORE YEAR FALL SEMESTER KINES 135
SAMPLE OF PRE-COURSE OCCUPATIONAL HEALTH QUESTIONNAIRE 2017
SAMPLE OF PRE-COURSE OCCUPATIONAL HEALTH QUESTIONNAIRE 2017 PLEASE NOTE THIS IS FOR GUIDANCE ONLY AND IS SUBJECT TO CHANGE PART A Applicant Personal Information PART B Applicant General Health Information
SHENANDOAH UNIVERSITY HEALTH FORM
SHENANDOAH UNIVERSITY HEALTH FORM Welcome to Shenandoah University. This cover letter is to help clarify the immunization and testing requirements for our Health Professions Programs. All students admitted
Special Category Volunteer Medical Packet
Special Category Volunteer Medical Packet Name: Date of Birth: Hospital policy mandates that each volunteer meets specific health requirements, including all information listed in this packet. Please use
Name Date. Date of Birth Social Security #: Street Address. City State Zip. Home Phone Cell Phone Address. Employer Business Phone
Barcode Label Interviewer: Office: **PLEASE USE BLACK INK** Patient Information Please Print Name Date Date of Birth Social Security #: Street Address City State Zip Home Phone Cell Phone E-Mail Address
University of Nebraska Omaha Athletic Performance Pre-Participation Medical History & Physical Examination Form TEAM TRYOUTS
Name (Last, First, MI) University of Nebraska Omaha Athletic Performance Pre-Participation Medical History & Physical Examination Form TEAM TRYOUTS of Birth Address Sex M / F Sport Phone City State Zip
Following this letter are health forms for parents or legal guardians to complete and sign. Please note that:
Summer Pre-College Programs Dear Summer Pre-College Student and Family, Welcome to Marist College! Please review the attached Health Forms. Students will be informed of health and emergency information
Vulnerable Sector Police
Seneca College Student Number: York Student Number: Seneca College Student E-Mail: York Student E-Mail: Students are required to: 1. Read the guideline document that accompanies this permit carefully for
REDDY & ASSOCIATES LLC D/B/A Reddy Medical Group D/B/A Reddy Urgent Care. Reddy Urgent Care Pre-Employment Physical Form
REDDY & ASSOCIATES LLC D/B/A Reddy Medical Group D/B/A Reddy Urgent Care 132 Franklin Springs St. 1061 Dowdy Road STE 100 280 General Daniels Ave. Royston, GA 30662 Athens, GA 30606 Danielsville, GA 30633
NORTH CAROLINA HIGH SCHOOL ATHLETIC ASSOCIATION SPORT PREPARTICIPATION EXAMINATION FORM
NORTH CAROLINA HIGH SCHOOL ATHLETIC ASSOCIATION SPORT PREPARTICIPATION EXAMINATION FORM Patient s Name: Age: Sex: This is a screening examination for participation in sports. This does not substitute for
Preadmission Health History and P hysical for NOVA Nursing Programs
Preadmission Health History and P hysical for NOVA Nursing Programs Form 125-017 Rev. 6/2016 INSTRUCTIONS TO STUDENT: This form must be filled out by applicant and a licensed primary care provider: physician,
ICSA Sports Physical Examination
Learning and Leading in a Collaborative Culture ICSA Sports Physical Examination (Circle One) MALE FEMALE What Sport do you plan to play? Student s Name: Date of Birth: M D Y Age: Grade / Class Address:
Student Health and Immunization Record
Student Health and Immunization Record Instructions for students: Health screening and immunization requirements for the Physician Assistant Program are based on current Centers for Disease Control recommendations
Adult Health History for NEW Patients
Adult Health History for NEW Patients Your answers on this form will help your health care provider get an accurate history of your medical concerns and conditions. If you are a current patient there is
THURGOOD MARSHALL ACADEMY PCHS ATHLETIC INFORMATION PACKET SY
THURGOOD MARSHALL ACADEMY PCHS ATHLETIC INFORMATION PACKET SY 2015-2016 THE INFORMATION CONTAINED IN THIS PACKET MUST BECOMPLETED BY BOTH THE STUDENT ATHLETE AND PARENT/GUARDIAN AND RETURNED TO MRS. THOMPSON,
Upper Iowa University Athletic Training. Name: Last First Middle. Home Address: Street Address City State Zip
Upper Iowa University Athletic Training MEDICAL HISTORY Personal Data Name: Last First Middle Home Address: Street Address City State Zip School Address: Street Address City State Zip Home Phone #: Cell
VGCC VANCE-GRANVILLE COMMUNITY COLLEGE
Student Medical Form VGCC VANCE-GRANVILLE COMMUNITY COLLEGE STUDENT MEDICAL FORM VANCE-GRANVILLE COMMUNITY COLLEGE INSTRUCTIONS FOR COMPLETING STUDENT MEDICAL FORM 1. Complete the four-page insert: Physical
STUDENT HEALTH SERVICES IMMUNIZATION FORM FOR GUILFORD COLLEGE 5800 West Friendly Avenue Greensboro, NC 27410
STUDENT HEALTH SERVICES IMMUNIZATION FORM FOR GUILFORD COLLEGE 5800 West Friendly Avenue Greensboro, NC 27410 P / 336-316-2194 F / 336-316-2184 A completed immunization record is required to be submitted
THIS FORM IS FOR MEDICAL STUDENTS ONLY IMMUNIZATION RECORD
Student Health Requirements Student health forms (physical exam and immunization records) are due in the Office of Clinical Education by March 1st for those students admitted on or before December 31st,
Student Health Services 100 East Brown Street (Phone)
Student Health Services 100 East Brown Street 272-762-4378 (Phone) East Stroudsburg, PA 18301 570-420-2447 (Fax) Dear Student: Congratulations and welcome to East Stroudsburg University. The Student Health
St Christopher Iba Mar Diop College of Medicine
St Christopher Iba Mar Diop College of Medicine Student Health History, Physical and Immunization Forms Please return all 3 parts of this form to: St Christopher Iba Mar Diop College of Medicine Department
Rutgers School of Nursing Center for Professional Development 65 Bergen Street, Room Newark, New Jersey 07107
p 973-972-6655 f 973-972-7904 Dear Participant, The attached health documentation is required for participation in the RN Skills Refresher course per University Policy and is for your protection as well
Name Date. Date of Birth Social Security #: Street Address. City State Zip. Home Phone Cell Phone Address. Employer Business Phone
Version 7/2/2015 Barcode Label Interviewer: Office: **PLEASE USE BLACK INK** Patient Information Private Health Patient Name Date Date of Birth Social Security #: Street Address City State Zip Home Phone
S Student Date of Birth (MM/DD/YYYY) Academic School Year Graduating Class
Student Last Name Student First Name Middle Initial 2018-2019 S Student Date of Birth (MM/DD/YYYY) Academic School Year Graduating Class Student ID Number Sport(s) of Interest (please list all) Athletic
Dear Student-Athlete,
Dear Student-Athlete, Welcome to Widener University. In order to keep you safe on and off the field there are certain physical requirements you must fulfill before participating in club sports. Please
2017/2018 MEDICAL FORM (For Season Ending June 2018)
2017/2018 MEDICAL FORM (For Season Ending June 2018) IMPORTANT NOTES TO APPLICANT 1. Please complete sections 1 & 2 of this form. Print clearly with a black ballpoint pen. These sections must be done prior
Student Health Services 881 Commonwealth Ave, West / Student Information (To be completed by the student) Student Name Last First Middle
Medical Clearance The following information must be completed on the medical history form, if any information is missing the form will be considered incomplete and will not be processed. If you have questions,
MARINA HS SPORTS PHYSICALS
MARINA HS SPORTS PHYSICALS WHEN May 30 th, 2018 @ 4pm8pm WHERE Marina Gymnasium COST $30 cash or check WHAT TO BRING Peach PHYSICAL FORM (with front side filled out) $30 CASH or CHECK made out to Marina
INITIAL MEDICAL PACKET
P a g e 1 INITIAL MEDICAL PACKET Name: Sport: Date: Last First Middle SSN: - - DOB: / / Age: Cell Phone: ( ) - Home Phone: ( ) - Family Physician: Phone: ( ) - Emergency contact: Name: Phone: ( ) - Relationship:
Student Health Medical Forms
LEHIGH UNIVERSITY Student Health edical Forms This form must be PRINTED, completed in its entirety and the original sent to: LEHIGH UNIVERSITY Health & Wellness Center 36 University Drive, Johnson Hall
Kinesiology Athletic Training
Kinesiology Athletic Training Department of Kinesiology Athletic Training Major Course Sequencing & Descriptions All courses require a grade of C or better for completion PRE-PROFESSIONAL PHASE: SOPHOMORE
Vulnerable Sector Police
Seneca College Student Number: York Student Number: Seneca College Student E-Mail: York Student E-Mail: Students are required to: 1. Read the guideline document that accompanies this permit carefully for
Washington & Jefferson College Report of Medical History
Report of Medical History To t h e St u d e n t: Please complete this side before going to your physician for examination. The reverse side is to be completed by your physician. This information is strictly
Volunteer Applicant Health Clearance Checklist
Volunteer Applicant Health Clearance Checklist Employee Health Contact Information Office Phone: (202) 715-4275; Fax: (202) 715-4587; Email: gwuehs@medcor.com Walk-in hours: M-F 8:00 a.m. 12:00 p.m. &
In order to enter St. Catherine of Siena School, all NEW students (Grades 1 5) must have (1) a pre entrance physical and (2) completed immunizations.
ST. CATHERINE OF SIENA SCHOOL Middle States Accredited 39 E. Bradford Avenue, Cedar Grove, NJ 07009 Telephone 973 239 6968 Fax 973 239 1008 www.scs school cedargrovenj.org TO: Parents of NEW Students Grades
Penn State New Kensington Radiological Sciences Program Physical Examination
Penn State New Kensington Radiological Sciences Program Physical Examination Personal Information (Student information) First Name: Middle Name: Last Name: Sex: Date of Birth (mm/dd/yyyy): Address: City:
3. State any instructions or limitations with which the student has been advised to comply. Please mark N/A if not applicable.
Health Care Provider Statement/Medical Release Prior to entrance into a health sciences program, a medical release must be completed by your health care provider. Note: If at any time during the program
Health Services & Sports Medicine Entrance / Pre-Participation Physical Exam
Full Name (First, Middle, Last): Health Services & Sports Medicine Entrance / Pre-Participation Physical Exam Sport (if athlete): Date of Birth: Social Security #: Home Address: Gender: Year in Sport:
***PLEASE RETURN ASAP***
***PLEASE RETURN ASAP*** UCSC WILDERNESS ORIENTATION MEDICAL FORM U. C. Santa Cruz, Wilderness Orientation, Office of P.E. & Recreation, Santa Cruz, CA 95064 Phone: (831) 459-2807 Dear Wilderness Orientation
Child Life Practicum
Child Life Practicum Thank you for your interest in the Child Life Practicum at Anne Arundel Medical Center in Annapolis, MD. This practicum program will allow a student insight into the daily duties of
* Health Insurance Verification Form, submitted on line. Click on link. Mandatory Health Insurance Verification Form
Residential Student: The Health Office welcomes you to residential living. It is our goal in collaboration with Residential Life, Safety, and Security, and the Dean of Students to promote health and wellness
Hospital of the University of Pennsylvania Occupational Medicine
Hospital of the University of Pennsylvania Occupational Medicine To: From: RE: All Incoming House Staff Amy J. Behrman, M.D. Medical Director Dorothy Dragoni, RN, BSN Surveillance and Compliance Coordinator
CERTIFICATE OF IMMUNITY
CERTIFICATE OF IMMUNITY ID# Select One: Harlem DO/MS Middletown DO/MS Class of TOURO COLLEGE OF OSTEOPATHIC MEDICINE 60 Prospect Ave, Middletown, NY 10940 Fax: (845)-648-1018 Name Sex Date of Birth Student
California Chiropractic Boshears, Inc Yucaipa Blvd., Yucaipa Ca Phone: (909) Fax : (909)
California Chiropractic Boshears, Inc. 35191 Yucaipa Blvd., Yucaipa Ca. 92399 Phone: (909) 790-5005 Fax : (909) 790-5009 Patient Information Date: Name: Address: Home Phone: Work Phone: Sex: Male or Female