Fillable Denmark Technical College Health & Physical Examination Form (Denmark Technical College)

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Denmark Technical College Health & Physical Examination Form (Denmark Technical College)

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Denmark Technical College
Health & Physical Examination Form
PLEASE PRINT
Last Name:______________________________ First Name:_______________________________________ Middle Initial:______
Date of Birth: ____/____/_____ Social Security #:___________/________/______________
Permanent Address:________________________________________________________________________
P. O. or Street City State Zip Code
Parent/Guardian:________________________________________ Phone: ( )_____________________
Emergency Contact Person:_______________________________ Phone: ( )_____________________
Address:__________________________________________________________________________________
P. O. Box or Street City State Zip Code
Type Hospital Insurance: Blue Cross/Blue Shield____________ Medicaid____________Other__________
Personal and Family Health History: Please answer all questions (comment on all “Yes” answers)
Have you or your family member ever had
Yes
No
Comments
Scarlet Fever
Measles
German Measles
Mumps
Chicken Pox
Malaria
Dental Problems
Sinusitis/Allergies
Problems with the Heart
High Blood Pressure
Diabetes
Problems with Lungs/TB
Impaired Visions
Impaired Hearing
Mental or Nervous Disorder
Migraine Headaches
Seizure Disorders
Drug Alcohol/Tobacco usage
Problems with the Liver/Hepatitis
Menstrual Problems
Cancer
Anemia/Sickle Cell Disease
Rheumatic Fever/Heart Murmur
Surgery/Hospital
Accidents Injuries
Hay Fever/Asthma
Stomach or Intestinal Problems
Allergies: drugs or food
Hyperventilation/Shortness of breath/hives
Disease or injury of bones joints
Venereal Disease
Recent loss or gain weight
Back Problems
Chronic Cough
Problems with eyes, ears, nose or throat
Complete and Mail to:
DTC Health Services Office
P.O. Box 327
Denmark, SC 29042
Phone: 803.793.5224
Fax: 803.793.5290/803.793.5942
Term of Enrollment: ___Fall ___Spring ___Summer ____ Year
CLINICAL EVALUTION: MUST BE FILLED OUT BY YOUR HEALTH CARE PROVIDER
Normal Abnormal Comment on all abnormal findings
Eyes
Ears
Nose/Throat
Thyroid
Skin
Heart
Lung
Breast
Abdomen
Spine
Extremities
Vascular System
Lymphatic System
Neuropsychiatry
Please list all medications that student is currently taking:
__________________________________________________________________________________________________
Comment on overall physical and emotional health status:
Can student participate in intramural/college sports if desired? Yes No, if no please explain below:
__________________________________________________________________________________________________
Please provide a plan of care and describe support/resource needed for any special problem or limitation:
__________________________________________________________________________________________
Required documentation of immunization based on South Carolina Immunization Laws and Denmark Technical
College Residential Life requirement. (Please attach a copy of your updated immunization records).
The following immunizations are required before being admitted into on-campus housing:
• Tetanus Booster (Date)________________________________________________________(Required every 10 years)
• Tuberculin Skin Test (PPD) (Date)_______________________________________________(Required within the last 12
months). If test is positive, a negative chest x-ray must be documented within six (6) months prior to admission.
• First MMR (Date)___________ Second MMR (Date)______________
(S. C. Law requires that student be given [Measles Live Virus] if he/she was born after 1957.)
Strongly Recommended Proof of Immunizations:
• Meningitis (Date) __________ Hepatitis B Series (Date #1)______ (Date #2)______ (Date #3)_______
Varicella (chickenpox) _______
Physician’s Signature/Title_________________________________________________________________________
Address_________________________________________________________________________________________
Telephone #______________________________ Date___________________________
This information is strictly for the use of the DTC Health Services Office and will not be released to another party without your knowledge and
written consent.
Revised Summer 2010
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Denmark Technical College Health & Physical Examination Form (Denmark Technical College)

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Completed 26 July 2020

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