International Student Program
Health Examination Report
7250 Mesa College Drive, San Diego, CA 92111-4998
Phone (619) 388-2717
Name: _____________________________ _________________________________ _________________________
(PLEASE PRINT) LAST FIRST MIDDLE
Country of Birth: _______________________________ Country of Citizenship: _______________________________
PART A. MEDICAL HISTORY: (TO BE COMPLETED BY STUDENT APPLICANT)
Have you had or do you now have any of the following conditions? If yes, give approximate dates:
Human Immune Deficiency Virus
Heart Problem (restrictions)
Other conditions (including but not
limited to learning disabilities):
_____________________
Any complications/restrictions due to the above conditions: NO YES, explain below:
___________________________________________________________________________________
Do you have any conditions that would affect your ability to enroll in a full time course load of study? NO YES, please
list conditions and limitations:
_________________________________________________________________________________________
Give date and types of serious operation or injuries: _____________________________________________________
I understand that falsification or withholding information on the Health Examination report shall constitute grounds for denial of
my application.
Applicant Signature: _______________________________ Date: ___________________________
PART B. MEDICAL CERTIFICATION: (TO BE COMPLETED BY PRIMARY CARE PROVIDER-PCP)
Current immunization and tuberculosis clearance with dates specified must be completed and verified before acceptance to
San Diego Mesa College.
1. Tetanus (
must be within the past nine years
). Date: ___________________
2. Measles (rubeola), Mumps, Rubella (
must be given after 1970 and after 12 months of age
).
Measles (rubeola) Date: ___________________ Mumps Date: ____________________ Rubella Date: ______________
3. Polio Date: ___________________ Diphtheria Date: ___________________
4. BCG inoculation Date: ________________________
If no BCG documentation, Tuberculosis clearance, dated within the past three months of the physical exam, complete
one of the following:
QuantiFERON blood test Date: ___________________ Result:___________________________________
Mantoux skin test Date: ___________________ Result*:___________________________________
*If Mantoux test is positive, chest x-ray is required.
Chest X-ray Date: ___________________ Result*:________________________________
*Attach copy of your chest x-ray report. Do not send the x-ray film.
Does student have any conditions which would affect the student’s ability to perform in an academic setting? No Yes,
explain:________________________________________________________________________________________
Special Health Problems, including conditions that would limit full-time study:
___________________________________________________________________________________________________________
I have examined _________________________________________and I find him/her in good health and able to attend college.
STUDENT NAME
Signature of PCP : ______________________________ Date: ____________________
Name of PCP: ___________________________________________________________
PLEASE PRINT
Address _____________________________________________________________
Email:_______________________________________________________________
Phone Number: _________________________ PCP Stamp or Business Card
