COLORADO COLLEGE HEALTH HISTORY & PHYSICAL EXAM FOR OFF CAMPUS PROGRAMS PARTICIPANT INSTRUCTIONS: Step 1: Complete Parts I & II of this form. Part III must be completed by a Physician, Nurse Practitioner, or Physician s Assistant. Physical exams for off-campus programs sponsored by Colorado College are available at Boettcher Health Center (BHC). Call 719-389-6384 to schedule an appointment. Bring all parts of this form to your appointment. Allow sufficient time to schedule an appointment in order to meet the deadline date set by the course instructor. Boettcher will keep a copy on file of any exam done at the Health Center should it be needed during your study abroad. Physical exams performed by BHC are valid for one year from the date of the exam. Step 2: Return the Health History and Physical Exam form to the Office of International Programs at Gill House. This form will be reviewed by the course Professor/Director, who may request follow-up information. If the student is under 18 years of age, a copy of the Authorization for Medical Care of a Minor must be attached to this document. PART I: TO BE COMPLETED BY THE STUDENT: (please write legibly) 1. Student Name: Location of off-campus program: Faculty Instructor: Date program starts: Birth date: Gender: Blood type: 2. Family History of Illness: TB Diabetes Sickle cell anemia Sudden death (answer yes or no) Cancer Depression Bipolar disorder Schizophrenia 3. Student s previous illness (answer yes or no; if yes, enter year, if known): ADHD/ADD Diabetes Hernia Panic Attacks Appendectomy Eating disorder High blood pressure Pneumonia Anemia Epilepsy Irregular heartbeat Skin disorder Alcohol/drug abuse Fracture/bad sprain Measles Suicide attempt Asthma Hay fever Migraines Tuberculosis Chicken pox Heart murmur Mumps Tonsillectomy Depression Hepatitis Mononucleosis Other 4. Allergies: Drug Materials Environmental Horse serum Antivenom Describe what happens when you have an allergic reaction 5. Allergy shots? No Yes If yes, for what? 6. Insect bite sensitivity? No Yes If yes, for which? 7. Food allergies: Describe what happens when you have an allergic reaction: _ February 2013 Page 1 of 5
8. Dietary restrictions: 9. Medications & dosages taken routinely: It will be your (student) responsibility to check with the U.S. Centers for Disease Control (CDC) to see if your prescriptions will be permitted to be brought into your host country. 10. Hospitalizations (date & diagnosis) 11. Surgeries (date & diagnosis) 12. Use tobacco? Quantity/day: Use alcohol? Quantity/week: Marijuana? Quantity/week: Other recreational drugs? Type Quantity/week: 13. Have you ever taken any medication in the past on a regular basis that was not an allergy medicine or an antibiotic? Name of medications: 14. Do you have any family or personal problems which might necessitate your returning home before the end of the off campus program? Please explain: 15. Is your general health: Excellent? Good? Fair? Poor? 16. Immunizations dates required, or mark here if a copy of your immunization record is attached: Polio (TOPV) Measles, Mumps, Rubella (MMR) Tetanus (Td) or Tdap TB test (PPD) Hepatitis B Meningitis Other shots 17. Are you now or have you ever been treated by a mental health professional, social worker, or counselor for a psychological or emotional problem? If yes, please explain below. Include the diagnosis or problem, and the treatment (medications, hospitalizations, etc). 18. Do you now have, or have you ever had an eating disorder, an alcohol or drug problem, periods of severe depression, or other mental health problems for which you have not received treatment? Please explain below. February 2013 Page 2 of 5
19. Do you think that you have any physical or medical condition that might prevent you from fully participating in or enjoying this program? If so, what accommodation do you believe would be necessary for you to complete a full program of study? 20. Insurance company: Policy number 21. Person to be notified in case of illness or injury: Name Relationship Telephone: ( ) Alternate telephone: ( ) PART II: TO BE SIGNED BY THE STUDENT; Please read carefully before signing. I certify that this Health History form, and all information contained in it, is complete and accurate, and that I am physically and emotionally fit to participate in this off campus program. I understand that providing inaccurate medical or mental health information or that falsifying medical or mental health information can create serious risks to my wellbeing, or to the well-being of other individuals who may accompany me on this program. I understand participation in this program is contingent upon having all parts of this form completed and signed. I will immediately inform the course professor/instructor/program staff if there has been any change in my medical condition, mental health or medical information between the time of the physical exam/ the completion of this form and the start of the program. I understand that if the examining medical provider feels that my medical history, chronic medical condition, mental health or findings on physical exam might hinder my participation, the provider may need to consult other sources. Therefore, by signing below, I give permission to the medical provider who is completing this form, to speak to other medical or mental health providers who have been involved in my care, the course professor/instructor/program staff, the Dean, and my parents/guardian. An emergency requiring treatment in a hospital and/or surgery may develop. In most cases, administration of an anesthetic, treatment of an injury, or operation upon an individual cannot be done without consent of the patient. In order to prevent a dangerous delay in an emergency situation where a representative of Colorado College is either unable to contact my parent/guardian or emergency contact, or if I am unconscious or otherwise unable to give you my consent, I hereby authorize the course professor/instructor/program staff representing Colorado College to secure whatever medical treatment is deemed necessary, including administration of an anesthetic and surgery. I understand that a representative of Colorado College will notify my emergency contact of my medical situation as soon as possible. I give the course professor/instructor/program staff representing Colorado College permission to share my medical information with any attending physician, should I be ill or injured. My consent is hereby granted to use the original or a photo copy as equally valid authorization. I certify that I am at least 18 years of age and understand and grant the permission and authorization delineated in Part II, above. This Health History form is accurate and complete. Please print your name Student signature Date February 2013 Page 3 of 5
Student name: CC ID# PART III: TO BE COMPLETED BY THE EXAMINING PHYSICIAN/PHYSICIAN ASSISTANT/NURSE PRACTIONER Height Weight BMI SP02 Temp BP HR RR Neuro / Psych Alert Slow / confused / lethargic Oriented Disoriented to time / place / person Mood / Affect normal Danger to self / others Psychosis Cranial Nerves Normal as tested EOM s intact EOM palsy Unequal pupils R pupil mm, L pupil mm Facial numbness CVS RRR Irreg rate and rhythm No murmur Extra systole No gallup Tachy / brady PMI displaced laterally Pulses (2+) JVD present Murmur grade 1-6 diastolic / systolic Gallup S3 / S4 Friction rub Pulses U / L extremities Sensory Motor No motor deficit No sensory deficit Reflexes Weakness Pronator drift (RUE, LUE) Sensory loss Abnormal reflexes Abdomen Non-tender Tenderness No organomegaly Guarding Nml bowel sounds Abnl bowel sounds inc / dec / absent Hepatomegaly Splenomegaly Mass HEENT Nml ENT inspection Pharynx nml Abnormal TM s (R/L) Throat red Septum perforated / deviated Back Nml inspection No veterbral tender CVA tenderness R / L Dental Nml dental inspection Dentures Carries Teeth broken / missing Eyes Glasses Contacts PERRLA Nystagmus Fundi normal Disconjugate gaze Mydriasis / meiosis / aniscoria Lacrimation Sclera injected / icteric Neck Nml inspection Thyromegaly Thyroid nml Lymphadenopathy Neck supple PND Nasal d / c Respiratory No resp distress Breath sounds nml Chest non-tender Wheezing Rales Rhonchi Home O2 Health History for Off Campus Programs 1/2013 Skin No rash Nml color Warm and dry No recent needle marks Extremities Non-tender Normal ROM No edema Atraumatic Cyanotic / diaphoretic Skin rash erythema, urticaria scaling, eczematous excoriated, macular papular, fine, patchy generalized, facial neck, arms, legs Jaundiced Abscess Lesions Needle marks Tattoos Edema hands / arms / legs ROM (continued on page 5) Page 4 of 5
22. List any physical or medical conditions that might affect the student s participation in the program. Include the diagnosis and treatment: 23. List any psychological problems that might affect the student s participation in the program. Include the diagnosis and the treatment: 24. List any health problems (such as eating disorders, alcohol or drug problem, period of severe depression or other mental health problems) for which the student has not received treatment but which could affect the student s participation in the program. Explain: 25. To the best of my knowledge the applicant is in With the following accommodation, the student should good physical and mental health and should be able to complete a full program of study off campus be able to complete a full program of study or in a foreign country: off campus or in a foreign country. Provider name (please print) Provider name (please print) Signature Date Signature Date February 2013 Page 5 of 5