Physical Examination And Health Documentation Form printable pdf download

College of Health, Education

Physical Examination and Health Documentation

and Professional Studies

PHYSICAL EXAMINATION AND HEALTH DOCUMENTATION FORM

A medical history and physical exam is required as part of student clinical requirements prior to

entry into a professional degree program at UTC. Immunizations, titers and TB skin tests must be

completed as part of this and then updated as necessary. The physical exam should be completed

using Parts I and II of this form by the student’s primary care provider or the University’s Student

Health Services.

The student must provide all information on Part I of the form as well as proof of titers received

(HepB series, Varicella, Rubella, Tetanus). The TB skin test or any needed vaccinations may be

administered by the student’s primary care provider or the University’s Student Health Services.

This form and all documentation of titers and TB skin test should be submitted to Student Health

Services for review and completion. Parts I and II of the form will be retained at Student Health

Services. Part III of the form will be returned to the student to submit to the appropriate

department with all other clinical requirements.

PART I: GENERAL INFORMATION

To be filled out by the student and submitted with Part II to primary care provider completing physical

examination.

Name: ____________________________________________________________________

Date: ____________________________

Street Address: ________________________________________________________________________________________________

City: _______________________________________________________

State: ________________

Zip: _________________

UTC MocsNet Id: ______________________________

Birthdate: ________________________________________

Phone Number: _______________________________

Date of Last Physical Exam: ____________________

Please check whether or not you now have or have had any of the following:

Condition

Yes

Describe

Allergy

Emotional Disorders

Hearing/Vision

Impaired

Heart Problem

Migraine

Diabetes Mellitus

Kidney Disease

Tuberculosis

Reviewed and updated: April 20, 2016

Physical Examination And Health Documentation Form