Cadet Consent For Medical Treatment (Page 3 of 6) in pdf

PHYSICIAN HISTORY & PHYSICAL EXAMINATION

NO SUBSTITUTION FORMS WILL BE ACCEPTED

ALL NEW AND RETURNING CADETS MUST HAVE A COMPLETED PHYSICAL EXAM.

Physical to be completed no earlier than June 1

of the incoming school year.

HEALTH CENTER PHONE: 610-989-1517 FAX: 610-989-1516

Name: ____________________________________________________ Date of Birth:__________________

YES

Allergies:

List allergies to medication, foods, bees, contrast dye, vaccines, etc. _______________________

YES

Past medical history:

Include all surgeries, hospitalizations, serious illness, and psychiatric issues.

Family History:

Is there any history of tuberculosis exposure?

YES

Is there any history of sudden death at a young age of parents, siblings, grandparents, cousins, aunts or uncles?

YES

Is there any history in the parents or siblings of childhood diseases, diabetes, heart disease, seizures or cancer?

YES

Social history:

Any history of tobacco, alcohol or drug use?

YES

Medications:

ist current medications and any past medications used on a regular basis.

Physical Examination:

Audiometer Hearing Screening:

Normal

Abnormal

Mandatory for grades 7 & 11.

Pulse __________

Vision:

20/_____ OS 20/ _____OD

Corrected

Uncorrected

Mandatory for all.

B/P

__________

Ht.

__________

Scoliosis Test:

Normal/Spine

Scoliosis

Mandatory for grades 6 & 7.

Wt.

__________

BMI

___________

Indicate treatment plan if applicable: _______________________________

Mandatory grades 7-12.

Immunizations – Mandatory for all

Attach Copy of Complete Immunization Record or Complete Immunization Form on (page 4).

Tuberculosis Screening – Mandatory for all:

•

All Cadets are required to have the PPD (topical skin test) planted within six months of arrival to school.

•

Those who reside outside of the United States will be tested upon arrival to VFMAC.

•

If the PPD induration result was greater than or equal to 10mm then a chest x-ray is required. Results of the x-ray must be

submitted to the VFMAC Health Center. Only chest x-rays performed in the United States will be accepted.

•

If there is a history of past treatment, provide documentation, to include name of medication, dates given, and length of

treatment.

PPD TEST DATE: ___________________ DATE READ: ___________________ INDURATION SIZE:____________________

Normal complete physical exam that includes:

Complete physical exam with the

emotional status, HEENT, teeth, heart, lungs, abdomen, G/U, neurological, skin,

following abnormalities:

musculoskeletal, lymph glands, genitalia.

Cadets at VFMA&C undergo vigorous physical conditioning. By signing below, I certify that the above information is correct for this Cadet and he/she is fully capable

of participating in all activities of the institution including, but not limited to, physical education, fitness training, and all athletic activities.

_______________________________________________

Physician/Office Stamp

Physician’s Signature

Print Physician’s Name

______________________________________________________

Address

_____________________________________________________________________

Phone _________________________________Fax

______________________________

Date of Exam