Physical Examination Form
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1
2PHYSICAL EXAMINATION FORM
Health Services Office
Loew Hall Rm. 101
2155 University Avenue
Bronx, NY 10453* Tel.718.289.5858 *
Fax.718.289.6074 * Alternate Fax.718.289.6347
Last Name____________________________________________FirstName__________________________Middle Initial ____
Please Print
Last 4 Digits of SS# ___ ___ ___ ___
Date of Birth ____ /___ /____ Date of Admission _______________________
Month
Day
Year
Sex: M___ F___ In Case of Emergency Notify _______________________ Telephone_________________________
PERSONAL MEDICAL HISTORY: If your response to any of the following is YES, please provide additional details in the space provided.
YES
NO
1. Has there been any significant medical illness, injury, weight loss in the past 12 months
2. Are you taking any medication? If yes, please list.
3. Are you under a physician’s care for containing medical problems?
4. Have you ever been an in-patient in a hospital?
5. Have you ever had an accident causing disabling injury?
6. Have you ever had a fractured bone?
7. Have you ever had a surgical operation?
8. Any history of a concussion, blackout, fainting, convulsion, recurrent dizzy spells, heat
exhaustion / heart stroke?
9. Do you wear eyeglasses, contact lenses, dentures or a hearing aid?
10. Do you have any allergies to medications, foods, or the environment?
11. Are you missing any organs or other body parts?
12. Do you have a history of high blood pressure, heart disease, irregular heart rate,
palpitations, diabetes, thyroid condition, liver, or kidney problems?
13. Any history of sudden death in your family (under age 50)?
14. Have you ever failed a physical examination for military service, employment, insurance or athletic competition?
LIFE STYLE QUESTIONS (TO BE ANSWERED BY THE STUDENT)
YES
NO
Do you smoke?
Do you exercise regularly?
Do you drink alcohol or take medication to relieve stress?
Do you have a problem with your weight?
Do you go for routine medical/dental checkups?
Have you ever gone for cancer screening?
Is your immediate family in good health?
Have you or a member of your family ever been a victim of a violent crime?
Have you ever used the emergency room for routine medical problems?
Private Insurance____
Medicaid____
None____
Specify Type of Health Insurance
Bronx Community College has a contract with Morris Heights Health Care Center located at 85 West Burnside Avenue, Bronx, New
York 10453 whereby registered students WITHOUT insurance have access to medical services offered at their facilities for a $10.00
co-payment. For an Appointment call (718) 483-1234. A physical exam is not necessary for registration.
ALL INFORMATION ON THIS PHYSICAL EXAMINATION FORM IS CONFIDENTIAL AND CANNOT BE RELEASED WITHOUT A
STUDENT’S WRITTEN CONSENT.
The preceding information is complete and correct to the best of my knowledge. I also authorize the release of this information the results of
this examination to the Bronx Community College Department of Health and Physical Education.
____________________________________________
______________________
Signature of Student
Date
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