Fillable Hudson Valley Health Science Physical Form

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Hudson Valley Health Science Physical Form

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The Hudson Valley Health Science Physical Form form is 1 page long and contains:

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Country of origin: US
File type: PDF

U.S.A. forms for Hudson Valley Community College

BROWSE HUDSON VALLEY COMMUNITY COLLEGE FORMS

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Report
_________
Received
_________
Approved
_________
This side to be completed by student
NAME
HVCC ID:
L
OCAL ADDRESS
DATE OF BIRTH
L
OCAL PHONE
CURRICULUM
P
ARENT OR GUARDIAN
FAMILY PHYSICIAN
AD
DRESS
ADDRESS
TE
LEPHONE
TELEPHONE
E
MERGENCY NUMBER FOR DAYS
Name Telephone Number
PERSONAL HISTORY
If you ever
have had or now have any of the following, check yes, if not please check no.
YES NO YES NO
Epilepsy ❑ ❑ Wear Glasses/Contact Lenses ❑ ❑
Diabetes
❑ ❑ Ear Trouble ❑ ❑
High Blood Pressure
❑ ❑ Heart Problems ❑ ❑
Eating Disorder
❑ ❑ Pain or Pressure in Chest ❑ ❑
Measles
❑ ❑ Palpitations or Pounding of Heart ❑ ❑
German Measles
❑ ❑ Cancer ❑ ❑
Mumps
❑ ❑ Frequent Indigestion ❑ ❑
Chicken Pox
❑ ❑ Sugar or Albumin in Urine ❑ ❑
Scarlet Fever
❑ ❑ Insomnia ❑ ❑
Whooping Cough
❑ ❑ Nervousness, Tension, Anxiety ❑ ❑
Rheumatic Fever
❑ ❑ Excessive Worry ❑ ❑
Asthma
❑ ❑ Depression ❑ ❑
Hay Fever ❑ ❑ Backache ❑ ❑
Chronic Cough
❑ ❑ Skin Disease ❑ ❑
Frequent Colds
❑ ❑ Trick or Locked Knee ❑ ❑
Frequent Sore Throats
❑ ❑ Current or Previous Occupational exposure
Bronchitis or Pneumonia
❑ ❑ to ionizing radiation. (If yes, have
Infectious Hepatitis
❑ ❑ current or past employer or
Infectious Mononucleosis
❑ ❑ monitoring company submit
Tuberculosis or Contact with Tuberculosis
❑ ❑ current cumulative dose.) ❑ ❑
Eye Trouble
❑ ❑
Give details of those checked YES
and approximate dates (if necessary, use additional sheet)
A
re you under the care of a physician?
❑ YES ❑ NO
Have you ever been hospitalized? ❑ YES ❑ NO
If yes, indicate where and for what reason
Do
you have ay mental or physical disability which would impair your ability to complete your chosen program?
❑ YES ❑ NO
Allergies
Food
*IMPORTANT - ALLERGIES TO DRUGS OR MEDICATIONS?
Are you presently taking medications? ❑ YES ❑ NO If so, state what and for what condition
INFORMATION ON THIS FORM MAY BE SHARED WITH YOUR DEPARTMENT CHAIRPERSON
AT THE DISCRETION OF THE COORDINATOR OF HEALTH SERVICES.
College Health Service
Health Science Physical Form
Please return this form to:
Hudson Valley Community College, College Health Service, 80 Vandenburgh Avenue, Troy, NY 12180
(This side to be completed by examining physician)
Height Build Blood Pressure _________________________
Weight
Pulse Hearing: Right ________________________
Left __________________________
Vision: Right 20/
Corrected to 20/ by contacts _____________________________
Left 20/
Corrected to 20/ by glasses ______________________________
CL
INICAL EVALUATION
GIVE DETAILS OF
Check each item in proper column NORMAL ABNORMAL EACH ABNORMALITY
& IDENTIFY BY NO.
1. Head, Neck, Face and Scalp
2
.Nose and Sinuses
3
.Throat
4
.Oral Cavity
5
. Ears (perforation or drum, etc.)
6. Ey
es (lids, conjunctiva, color blindness, etc.)
7.
Pupils and ocular motion
8. Lu
ngs, chest, and breasts
9. Hea
rt (include estimate of cardiac function)
10
. Vascular system (varicosities, etc.)
11
. Abdomen and viscera (include hernia/other disorders)
12. An
o-rectal (pilonidal cyst)
13
. Endocrine system
14
. G-U system
15. Up
per extremities (strength/movement)
16
. Feet
17
. Lower extremities (as for uppers)
18
. Spine, other musculo-skeletal
19
. Skin and lymphatics
20
. Neurologic
21
. Psychiatric
* IS
THIS STUDENT PHYSICALLY ABLE TO PARTICIPATE IN UNLIMITED PHYSICAL ACTIVITY
INCLUDING INTERCOLLEGIATE ATHLETIC PROGRAM AND/OR AN ROTC PROGRAM?
YES
NO
If no, please cite reasons.
________________________________________________________________________________________________
Summary and additional comments.
AL
L THESE REQUIREMENTS MUST BE MET BEFORE ENROLLMENT
SEE ATTACHED SHEET FOR SUPPLEMENTAL TESTS AND IMMUNIZATION REQUIREMENTS.
Type or Print Name of Examining Physician Signature of Examining Physician
*Practice stamp required*
ADDRESS:
LICENSE NO.: ____
DATE: ________________________________________
PHONE:
INFORMATION GIVEN ON THIS FORM MAY BE
SHARED WITH YOUR DEPARTMENT CHAIRPERSON
AT THE DISCRETION OF THE COORDINATOR OF HEALTH SERVICES.
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Hudson Valley Health Science Physical Form

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Completed 19 February 2020

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