DIOCESE OF WORCESTER. Medical History and Physician s Report

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1 DIOCESE OF WORCESTER Medical History and Physician s Report Last Name First Name Middle Initial Social Security Number Sponsoring Diocese Date of Birth Diocese of Worcester Contact Information Street Address P.O. Box Apartment Number City State Zip Code Home Phone Cell Phone Work Phone Address Web-site Next of Kin Name (First, Middle Initial, Last) Street Address P.O. Box Apartment Number City State Zip Code Home Phone Cell Phone Work Phone Address Relationship Revised June 2005

2 Family History Father Mother Brothers: Age State of Health Occupation Age at Death Cause of Death Sisters: Have any of your relatives ever had any of the following? Illness Yes No Relationship Tuberculosis Diabetes Kidney Disease Heart Disease Arthritis Stomach Disease Asthma/Hay Fever Cancer High Blood Pressure High Cholesterol Stroke Neurological Disorders (e.g. ADD/ADHD) Schizophrenia/Psychosis MEDICAL HISTORY AND PHYSICIAN S REPORT 2

3 Personal History Please answer all questions. Comment on all positive answers in the space below or on a supplemental sheet. Have you had: Yes No Have you had: Yes No Have you had: Yes No Scarlet Fever Hypoglycemia Frequent Anxiety Measles German Measles Mumps Chicken Pox Infectious Mononucleosis History Seasonal Allergies Drug Allergies (which) Food Allergies (which) Serum Allergies (type) Bee Sting Allergy (describe type reaction) Albumin/Sugar in Urine Skin Rashes/Sores Eczema Psoriasis High or Low Blood Pressure Elevated Cholesterol Level Rheumatic Fever Heart Murmur Pain/Pressure in Chest Shortness of Breath Depression Obsessive Compulsive Disorder Frequent Nausea/Vomiting Stomach or Intestinal Problem Hernia Rectal Problem/Hemorrhoids Gallbladder Disease/Gallstone Jaundice Recurrent Urinary Tract Infection Prostatitis/Epididymitis Other Allergy Palpitations (Heart) Kidney Stones Pneumonia Phlebitis Sexually-Transmitted Disease Chronic Cough Varicose Veins Frequent Urination Recurrent Colds Neuritis/Neuralgia Trick Knee, Shoulder Recurrent Sinus Infections Recurrent Headaches Deviated Septum Migraine Headaches Bursitis Asthma Head Injuries with Unconsciousness Arthritis/Arthralgia Back Problems Eye/Vision Problem Seizure Disorder Tumor, Cyst Hearing Problem Dyslexia Cancer MEDICAL HISTORY AND PHYSICIAN S REPORT 3

4 Frequent Ear Infections Hoarseness ADD/ADHD Other Learning Differences Anemia Immune Deficiency Fevers/Sweats Tics Other Blood Disorder Weight Loss/Gain Weakness, Paralysis Change in Appetite Dizziness/Fainting Surgery: Do you bleed or bruise easily? (If so, is this new?) Diabetes Insomnia Appendectomy Tonsillectomy/ Adenoidectomy Hernia Repair Other Surgery and/or Hospitalizations: Surgeries Type of Surgery Year Hospitalizations Reason Year Transfusions or blood products ever received? Yes No Last EKG Last Chest X-Ray Other X-Rays in the last five years Last general physical examination Last general blood chemical studies Are you currently taking any medications? (Include any over the counter medications) Check conditions and indicate medications: Allergies Diabetes Insomnia Colds Seizure Disorder Neurological Disorder Constipation Headaches ADD Cough Indigestion Depression MEDICAL HISTORY AND PHYSICIAN S REPORT 4

5 Medications used regularly: Medications used occasionally: Do you wear eyeglasses or contact lenses? Yes No When was your last vision check? Do you use a hearing aid? Yes No When was your last hearing check? When was your last rectal exam? How would you describe your appetite? Good Fair Poor Approximately how many urinary trips do you make during the day? Approximately how many urinary trips do you make during the night? Do you drink alcoholic beverages? If yes, indicate the frequency. Yes Frequency No Do you now, or have you in the past, used illegal drugs? If yes, indicate the nature and frequency of use: Yes No Nature and Frequency of Use Symptoms: do you have or have you had any of the following symptoms within the past year? Please answer all questions. Comment on all positive answers in the space below or on a supplemental sheet. SYMPTOM YES NO SYMPTOM YES NO SYMPTOM YES NO Headaches Sore Throat Heart Flutter Fainting Spells Unconsciousness Vision Trouble Ringing in Ears Decreased Hearing Nose Bleeds Frequent Colds Sore, Easily-Bleeding Gums Blood in Bowel Movements Change in Diameter of Bowel Movements Pain with Bowel Movements Change in Color of Bowel Movements Accidental Loss of Urine Easy Tiring High Blood Pressure Ankle and/or Foot Swelling Leg Cramps Enlarged Leg Veins Abdominal Pains Belching; Heartburn Nausea; Vomiting Sinus Trouble Chest Pain Vomited Blood MEDICAL HISTORY AND PHYSICIAN S REPORT 5

6 Altered Taste or Smell Hoarseness Difficulty Swallowing Enlarged Glands; Lumps Coughing Blood Recurring Cough Shortness of Breath Purple Lips and/or Fingers Aversion to any Foods Numbness or Tingling Rashes Urinary Symptoms MEDICAL HISTORY AND PHYSICIAN S REPORT 6

7 Physical Examination Examining Physician: Please review the applicant s history and complete the following pages. Please comment on all positive answers and indicate the following: O=Negative N=Normal X=Not Examined GENERAL COMMENTS: Blood Pressure Heart Rate Heart Rhythm Eyes Fundi Uncorrected Vision Near: Distant: Corrected vision Near: Distant: Other comments regarding vision: Ears Nose Throat Face Mouth Chest (Excursions) Neck Heart Skin Abdomen, Inguinal, Femoral Hernia Back and Spine Arms Legs Neuromuscular Genitourinary Rectal Prostate Genitalia Musculoskeletal MEDICAL HISTORY AND PHYSICIAN S REPORT 7

8 Metabolic/Endocrine Neuro-psychiatric Gastrointestinal Hearing Height inches Overweight Weight - pounds Underweight Recommendations for physical activity (PE, intramurals, sports): Please explain: Unlimited Limited Do you have any recommendations regarding the care of this student? Yes No Please explain MEDICAL HISTORY AND PHYSICIAN S REPORT 8

9 Is the patient now under treatment for any medical or emotional condition? Yes No Please Explain Is there loss or seriously impaired function of any organ? Yes No Please Explain Immunizations (Vaccines) The following are the immunization requirements for acceptance into the Diocese of Worcester, as recommended by the Massachusetts Department of Health. Please indicate the vaccination by month and year DTP (childhood) or DT (Adult Diphtheria-Tetanus): Basic series of three doses required. DIPHTHERIA-TETANUS BOOSTER: Required within last ten years. May be part of above DT series. POLIO: Three doses required ONLY if under age 18. VARICELLA: Either a history of chicken pox, a positive Varicella antibody, or two doses of vaccine given at least one month apart if immunized after age 13 years meets the requirement. Vaccination (MM-YYYY) Vaccination (MM-YYYY) Date Varicella Disease Date Positive Varicella Titer MEDICAL HISTORY AND PHYSICIAN S REPORT 9

10 M.M.R. (MEASLES/MUMPS/RUBELLA): Two doses required. Dose 2 must be given at least one month after first dose. Date of Vaccination: Dose 1 Date of Vaccination: Dose 2 HEPATITIS B: All entering students should have begun or completed the Hepatitis B vaccine series (three doses). Positive Hepatitis B surface antibody meets the requirement. Please indicate the vaccination by month and year Dose 1 Dose 2 Dose 3 Hepatitis B Surface Antibody Date (MM-YYYY) Result Reactive Non-Reactive MENINGOCOCCAL: (One dose preferably at entry into college for students who wish to reduce their risk of meningococcal disease. Students with immunodeficiency such as complement deficiency or asplenia should receive vaccine every three to five years.) Vaccine or signed waiver required by Massachusetts State Law. Date: Quadrivalent polysaccharide vaccine Required Test: (MM-YYYY) Result TUBERCULOSIS TEST(S): Required within last twelve months OR Skin Test: CHEST X-RAY if skin test was positive. Chest X-ray LABORATORY ANALYSES The following laboratory work needs to be completed. Please indicate and explain the significance of the results. CBC SMA-6 SMA-12 T3 T4 MEDICAL HISTORY AND PHYSICIAN S REPORT 10

11 TSH Lipid Analysis Urinalysis HIV Test Specimen Type Test Result Blood: finger stick Positive/Reactive Blood: venipuncture NAAT-pos Blood: finger stick Negative Blood spot Indeterminate Oral mucosal transudate Urine Additional Remarks or Comments by examining Physician Physician s Information Name (please print) Telephone: ( ) City State Zip Code Signed: Title Date: MEDICAL HISTORY AND PHYSICIAN S REPORT 11

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