Institute for Continuing Theological Education Pontifical North American College
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1 Institute for Continuing Theological Education Pontifical North American College Vatican City State Europe Medical History and Physician s Report (Applicant completes pages 1-to-3 before taking this form to physician) Last Name First Name Middle Initial Diocese / Religious Community Social Security Number Medical Insurance Provider Policy Number Type / Nature of Policy Date of Expiration (MM/DD/YY) Date of Birth mo day year Personal Medical Background 1) Have you ever been hospitalized or had surgery? If YES, list the following: Reason for Hospitalization age Year Type of Surgery Year 2) Have you ever been in a serious accident? If YES, give the date and describe the medical findings: 3) Have you ever had an allergic reaction to any medication(s)? If YES, please list the generic name of the medication(s) and its purpose: ICTE: Medical History and Physician s Report Page 1 of 6
2 4) Do you take any medication(s) regularly? If YES, please list the generic name of the medication(s) and its purpose: 5) Do you have allergies (seasonal, food, bee sting, other)? If YES, please describe: PERSONAL HISTORY 6) Please answer all questions. Add applicable comments on all YES answers on a supplemental sheet. Have you had: Yes No Age Have you had: Yes No Age Scarlet Fever Hypoglycemia Frequent Anxiety Measles Albumin / Sugar in Urine Depression German Measles Skin Rashes / Sores Obsessive Compulsive Disorder Mumps Eczema Frequent Nausea / Vomiting Chicken Pox Psoriasis Stomach / Intestinal Problem Infectious Mononucleosis High or Low Blood Pressure Hernia Diabetes Elevated Cholesterol Level Rectal Problem / Hemorrhoids Rheumatic Fever Gallbladder Disease / Gallstone Heart Murmur Jaundice Pain / Pressure in Chest Recurrent Urinary Infection Shortness of Breath Prostatitis / Epididymitis Palpitations (Heart) Kidney Stones Pneumonia Chronic Cough Varicose Veins Frequent Urination Recurrent Colds Neuritis / Neuralgia Trick Knee, Shoulder Recurrent Sinus Infections Recurrent Headaches Arthritis / Arthralgia Deviated Septum Migraine Headaches Bursitis Peptic Ulcer Back Problems Seizure Disorder Tumor, Cyst Hearing Problem Dyslexia Cancer Frequent Ear Infections ADD / ADHD Anemia Hoarseness Immune Deficiency Fevers / Sweats Tics Other Blood Disorder Weight Loss / Gain Weakness / Paralysis Dizziness / Fainting Asthma Insomnia Appendectomy Tonsillectomy / Adenoidectomy Hernia Repair Epilepsy Tuberculosis Hepatitis Head Injuries with Unconsciousness ICTE: Medical History and Physician s Report Page 2 of 6
3 7) Do you wear corrective lenses? If YES, please indicate prescription: Left Right Date of Last Vision Exam (MM/YY) 8) Have you ever received blood transfusions or blood products? If YES, please explain: 9) Are you currently taking any medications? (Include any over-the-counter medications) Check conditions and indicate medications: Allergies Cough Headaches Neurological Disorder Colds Diabetes Indigestion ADD Constipation Seizure Disorder Insomnia Depression Medications used regularly: Medications used occasionally: Immunizations Date (MM/YY) Small Pox Tetanus Cholera Poliomyelitis Typhoid Tuberculin Test Date (MM/YY) Father Mother Brothers: Family History Age State of Health Occupation Cause of Death (if applicable) Sisters: Have any of your relatives ever had: Yes No Relationship Have any of your relatives ever had: Yes No Relationship Tuberculosis Cancer Diabetes Asthma Kidney Disease High Blood Pressure Heart Disease High Cholesterol Arthritis Stroke Stomach Disease Schizophrenia / Psychosis ADD/ADHD ICTE: Medical History and Physician s Report Page 3 of 6
4 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: Heart Blood Pressure Heart Rate Heart Rhythm Eyes Uncorrected Vision Near Corrected vision Other comments regarding vision: Distant 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 Metabolic/Endocrine Neuro-psychiatric Gastrointestinal Hearing ICTE: Medical History and Physician s Report Page 4 of 6
5 Height (inches) Weight (pounds) Overweight Underweight Recommendations for physical activity (PE, intramurals, sports): Unlimited Limited Do you have any recommendations regarding the care of this patient? Is the applicant now under treatment for any medical or emotional condition? Is there loss or seriously impaired function of any organ? Laboratory Analysis The following laboratory work needs to be completed. * Please attach a copy of the lab results. Also, you are asked to indicate and explain the significance of the results in the space provided.. CBC Chemistry Profile (e.g. SMA) HIV Antibody Urinalysis ICTE: Medical History and Physician s Report Page 5 of 6
6 Additional Remarks or Comments by examining Physician Patient s Present Health Condition: Are there any restrictions to medicines, diet, and physical exercise? If YES, please explain: Does the applicant s past medical history indicate anything significant in view of his expected living and continuing education in Rome over the next few months? If YES, please explain: CHALLENGES of the INSTITUTE IN ROME: (Capability rating: 1 = capable / 2 = moderately capable / 3 = incapable) CAPABILITY: General: - Four hours/day classes; five days/week One-two hours of religious commitment Pilgrimages & sight-seeing: varies per day (2 4 hours optional) Rigors of the schedule Extensive periods of city walking at times ICTE: Medical History and Physician s Report Page 6 of 6
7 (Capability rating: 1 = capable / 2 = moderately capable / 3 = incapable) Mediterranean environment: - Allergic reaction due to high pollen count Damp environment / heating system compromised at times Sudden air pressure changes causing headaches Catacombs (40 feet underground) Hilly and cobblestone terrain Significant cultural challenges due to American Ethnocentrism - Fast moving city Crowded buses Common spoken language is Itlalian Facilitating Euro currency Italian meal schedules High salt content & spices in Mediterranean food In your physical & medical assessment, would you recommend this person at this time for the program? YES NO Physician s Information Name (please print) Telephone Address City State/Province Country Zip/Post Code Physician s Signature: Date: ICTE: Medical History and Physician s Report Page 7 of 6
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Creve Coeur Family Medicine, LLC Patient Name: Date of Birth: Medication List Medication Name (Over the counter medications too) Strength/ Dose (mg) Number of pills per dose Number of times per day Personal
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Name DOB Sex Age Date MR# PLACE CHARGE TICKET LABEL IN THE DASHED SPACE OR COMPLETE THE ABOVE: PLEASE ANSWER EACH QUESTION AS CORRECTLY AS YOU CAN BY PLACING AN "X" IN APPROPRIATE BOX What is the reason
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Consultant Name: NEW PATIENT QUESTIONNAIRE Health Care Analysis CONGRATULATIONS! You ve taken an important step in your commitment to managing your weight. We look forward to working with you. Our Program
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: