New Student Medical History And Physical Examination Form (Page 2 of 4) in pdf

Page 2 of 4

TUDENT

EDICAL

ISTORY AND

HYSICAL

XAMINATION

Lawrence University Health Services • 711 E. Boldt Way • Appleton, WI 54911‐0599 • Phone: 920‐832‐6574 • Fax: 920‐832‐7488

D. Medical History ‐ ‐ ‐ ‐ Explain “Yes” answers below. Circle any questions you don’t know the answer to.

FAMILY HISTORY – Has anyone in your immediate family experienced any of the following?

Yes

Abnormal Heart Rate/Palpitation

Heart Murmur

Blood Disorder

High Blood Pressure/Hypertension

Diabetes

Marfan Syndrome

Epilepsy

Psychiatric Illness

Heart Disease/Heart Attack

Sudden Death (before 50)

PERSONAL HISTORY – Have you ever experienced or do you currently have any of the following conditions?

Yes

ADD/ADHD

Hearing Impairment/Loss or Ear Problems

Anemia

Physical Handicap

Asthma/Breathing Problems

Skin Conditions (ie: rash, acne, warts, infections)

Autism/Aspergers

Syndrome Sleep Disorder

Diabetes (Type I or II)

Tested positive for Sickle‐Cell Trait or Disease

Eating Disorder

Tumor/Growth/Cancer/Cyst

Emotional Disturbance (Anxiety/Depression)

Visual Impairment/Loss or Eye Problems

Emotional Trauma

Other:

GENERAL QUESTIONS

Yes

BONE AND JOINT QUESTIONS

Yes

1. Medical illness or injury since last check‐up?

27. Use any equipment or devices not usually used for your sport or

position (pads, braces, neck roll, orthotics, mouth guard, etc)?

2. Chronic illness or condition?

3. Ever hospitalized overnight?

28. Have a pin, screw or plate in your body?

4. Ever had surgery?

29. Ever had a stress fracture?

5. Doctor ever denied/restricted sports participation?

30. Ever had an injury that required x‐ray, MRI, CT scan, brace, cast

or crutches?

HEART HEALTH QUESTIONS

Yes

6. Ever passed out/ lightheaded/dizzy during or after exercise?

If yes to the following questions, check appropriate body part and explain:

7. Ever had chest pain during or after exercise?

31. Ever broken/fractured any bones / dislocated or sublexed joints?

8. Heart race or skip beats during exercise?

32. Ever had a sprain, strain or swelling after injury?

9. High blood pressure or high cholesterol?

33. Ever had other problems with pain or swelling in muscles,

tendons, bones or joints?

10. Heart murmur?

11. Do you tire more quickly than peers during exercise?

□

Head

□

Neck

□

Spine

12. Severe viral infection (myocarditis, mononucleosis, etc)?

□

Chest

□

Back

□

Shoulder

MEDICAL QUESTIONS

Yes

□

Upper Arm

□

Elbow

□

Forearm

13. Born without/are missing kidney, eye, spleen, other organ?

□

Wrist

□

Hand

□

Back

14. Cough/wheeze/trouble breathing during or after activity?

□

Hip

□

Thigh

□

Knee

15. Head injury/concussion? (If so, how many and when?)

□

Shin/Calf

□

Ankle

□

Foot

16. Ever knocked out, become unconscious, lost memory?

EXPLAIN ANY “YES” ANSWERS BELOW:

17. Ever had a stinger or a burner?

18. Ever had a seizure?

19. Ever had numbness/tingling in arms, hands, legs or feet?

20. Frequent or severe headaches?

21. Ever become ill from exercising in the heat?

22. Wear glasses, contacts or protective eyewear?

23. Wear dental appliances?

24. Worry about your weight?

25. Special diet? Avoid certain foods?

26. Significant weight change recently?

34. Any concerns you wish to discuss with a doctor?

□ Yes

□ No

*If you are/become a student-athlete, you also understand and agree that the Lawrence University Athletics Department will have access to this

information.* I hereby certify that, to the best of knowledge, the information provided on this form is complete and correct.

Signature of Student _____________________________________________

Date _____ /_____ /________

STANDING CONSENT FOR ROUTINE TREATMENT OF MINORS

I, the undersigned parent/guardian of the above named student, hereby give my consent for the provision of routine health care to said child by health

care providers & staff of Lawrence University Health & Counseling Services. This care may be routine diagnostic procedures, examinations, medical

treatment, routine laboratory tests, X‐rays, health & wellness counseling, and the administration of prescribed medication. This consent shall be valid for

the period of time commencing on the date of student arrival on campus until the student’s 18th birthday. I do hereby indemnify and hold harmless the

health care providers and entities and other persons who act in reliance upon this consent. I also authorize treatment by a physician at a local medical

facility in the event of an emergency.

Signature of Parent/Guardian _____________________________________

Date _____ /_____ /________