International Student Program
7250 Mesa College Drive, San Diego, CA 92111-4998
(619) 388-2717 (619) 388-2960 FAX
Name: Date:
Country of Birth Country of Citizenship
Have you had or do you now have any of the following conditions? If yes, give approximate dates:
Allergy (severe) Epilepsy Polio Any Problems now?
Anemia Hepatitis Migraine headaches
Asthma Malaria Rubella (German Measles)
Blackouts Measles (Rubeola) Thyroid Problem
Chicken Pox Meningitis Tuberculosis
Diabetes Mononucleosis Heart problem Restrictions
High Blood Pressure Kidney disease Intestinal problems
Rheumatic Fever Any complications/restrictions
Stomach ulcer HIV (Human Immune Deficiency Virus)
Do you take any medication regularly? Yes No If yes, give names:
Give dates and types of serious operations or injuries:
Explain special health problems.
1. Tetanus (must be within the past nine years): Date:
2. Measles, Rubella (must be given after 1970 and after twelve months of age):
Measles (Rubeola) Date: Rubella Date:
3. Polio Date: Diphtheria Date
4. BCG inoculations Date:
If no BCG, Tuberculosis clearance dated within the past three months of this physical exam:
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 condition which would prevent participation in physical education? Yes________ No _____
If yes, explain: _________________________________________________________________________________
Special Health Problems: _________________________________________________________________________
I have examined (student’s name)__________________________________________
and find him/her in good health and able to attend college.
Signature of Physician __________________________________ Date: ____________
Name of Physician (please print)___________________________________________
Address: ______________________________________________________________
Phone Number or Email__________________ Physician Stamp or Business Card Here
This form is also available online at:
Current immunizations and tuberculosis clearance with dates specified must be completed and verified before
acceptance at San Diego Mesa College.
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