Student Health Center - University of Wisconsin Oshkosh

Medical History & Physical Form - International Students

Student's Name:	_____________________________________________________________________
	(Family name)	(First Name)	(Middle Name)

Date: ____________________

Date of birth: ____________________

Sex : (_) M (_) F

Address: _____________________________________________________________________________

_____________________________________________________________________________

Phone: ________________________

Check Circles if Yes

(_)	Allergy	_____________________________________________
(_)	Medicine	_____________________________________________
(_)	Asthma
(_)	Other	_____________________________________________

Use:

(_)	Drugs	Tobacco
(_)	Alcohol	(_)	Chew
		(_)	Smoke

Immunizations

		Date			Date
(_)	Polio	__________	(_)	Tetanus	__________
(_)	Rubella	__________	(_)	Diptheria	__________
(_)	Measles	__________	(_)	Whooping cough	__________
(_)	Mumps	__________	(_)	Hepatitis	__________
(_)	Bacille Calmette Guerin (BCG)				__________
(_)	Other	___________________________________________________

Family History

	Father	Mother	Father's Parents	Mother's Parents	Siblings	Children
Heart disease	(_)	(_)	(_)	(_)	(_)	(_)
High Colesterol	(_)	(_)	(_)	(_)	(_)	(_)
Stroke	(_)	(_)	(_)	(_)	(_)	(_)
High Blood Pressure	(_)	(_)	(_)	(_)	(_)	(_)
Cancer	(_)	(_)	(_)	(_)	(_)	(_)
Diabetes	(_)	(_)	(_)	(_)	(_)	(_)
Gout	(_)	(_)	(_)	(_)	(_)	(_)
Alcoholism	(_)	(_)	(_)	(_)	(_)	(_)
Mental illness	(_)	(_)	(_)	(_)	(_)	(_)
Epilepsy	(_)	(_)	(_)	(_)	(_)	(_)
Headaches	(_)	(_)	(_)	(_)	(_)	(_)
Bleeding disease	(_)	(_)	(_)	(_)	(_)	(_)
Kidney disease	(_)	(_)	(_)	(_)	(_)	(_)
Tuberculosis	(_)	(_)	(_)	(_)	(_)	(_)

Check Circles if you have or have had

(_)	Eye problem	(_)	Depression	(_)	Skin problem	(_)	Female problem
(_)	Glasses	(_)	Anemia	(_)	Lung problem	(_)	Penis, testicle problem
(_)	Headaches	(_)	High cholesterol	(_)	Liver, stomach, bowel problem	(_)	Sexually transmitted disease
(_)	Head injury	(_)	Diabetes	(_)	Urine, kidney problem	(_)	AIDS
(_)	Deafness	(_)	High blood pressure	(_)	Arthritis	(_)	Other ilness
(_)	Dizziness/fainting	(_)	Heart Problem	(_)	Bone, joint injury	________________________
(_)	Hospitalization	___________________________________________________________
(_)	Surgery	___________________________________________________________
(_)	Taking any medicine	___________________________________________________________
(_)	History of Isoniazid Hydrazid (INH) Prophylaxis			__________________________________________
(_)	Contact with a person with tuberculosis			_________________________________________

Student/Patient Comment:

_________________________________________________________________________

_______________________________

^{Student/Patient Signature}

University of Wisconsin Oshkosh, Student Health Center, Radford Hall, Oshkosh, WI 54901-8694 U.S.A

Section 2

Student Health Center - University of Wisconsin Oshkosh

Physical Examination Form - International Students

Name__________________________________________________________

Date______________

Age
_____________ Height
_____________ Temp
_____________

Race
_____________ Weight
_____________ Resp
_____________

Pulse: Resting
_____________ 2 min. after exercise
_____________

Normal Abnormal Deferred Normal Abnormal Deferred

Head, Face (_) (_) (_) Abdomen (_) (_) (_)

Eyes (_) (_) (_)
Hernia
(_) (_) (_)

Vision
(_) (_) (_) Genitalia (_) (_) (_)

Color-vision
(_) (_) (_) Rectum (_) (_) (_)

Ears (_) (_) (_)
Prostate
(_) (_) (_)

Hearing
(_) (_) (_) Back (_) (_) (_)

Nose, Sinuses (_) (_) (_) Extremities (_) (_) (_)

Oral Cavity (_) (_) (_)
Upper Extrem
(_) (_) (_)

Neck, Jaw (_) (_) (_)
Lower Extrem
(_) (_) (_)

Chest (_) (_) (_) Vascular (_) (_) (_)

Breasts (_) (_) (_) Neuromuscular (_) (_) (_)

Lungs (_) (_) (_)
Reflexes
(_) (_) (_)

Heart (_) (_) (_)
Rhomberg
(_) (_) (_)
Skin, Nails (_) (_) (_)

	Normal	Abnormal	Deferred		Normal	Abnormal	Deferred
Head, Face	(_)	(_)	(_)	Abdomen	(_)	(_)	(_)
Eyes	(_)	(_)	(_)	Hernia	(_)	(_)	(_)
Vision	(_)	(_)	(_)	Genitalia	(_)	(_)	(_)
Color-vision	(_)	(_)	(_)	Rectum	(_)	(_)	(_)
Ears	(_)	(_)	(_)	Prostate	(_)	(_)	(_)
Hearing	(_)	(_)	(_)	Back	(_)	(_)	(_)
Nose, Sinuses	(_)	(_)	(_)	Extremities	(_)	(_)	(_)
Oral Cavity	(_)	(_)	(_)	Upper Extrem	(_)	(_)	(_)
Neck, Jaw	(_)	(_)	(_)	Lower Extrem	(_)	(_)	(_)
Chest	(_)	(_)	(_)	Vascular	(_)	(_)	(_)
Breasts	(_)	(_)	(_)	Neuromuscular	(_)	(_)	(_)
Lungs	(_)	(_)	(_)	Reflexes	(_)	(_)	(_)
Heart	(_)	(_)	(_)	Rhomberg	(_)	(_)	(_)
				Skin, Nails	(_)	(_)	(_)

Mantoux Tuberculin Skin Test: (must have been administrated within last year)

Date Given: ________ Date Read: _________ Result: ________mm(induration only)

(Chest x-ray required if Mantoux test has form 10mm or more induration)

Chest x-ray:

Date taken:____________ Result:_______________________________________________

Urinalysis________________________________________________________________________________

Complete Blood Cell Count (CBC):___________________________________________________________

Syphilis Test:_____________________________________________________________________________

Sports Activity: (_) Restricted (_) Unrestricted

Physician Comments/Advice:

_________________________________________________________________________

Physican's Signature_____________________________Print Name______________________________

Adress:________________________________________________________Phone:____________________

Reviewed by Student Health Center-Dr.__________________________________________

Date____________________________Approved________________________

Age	_____________	Height	_____________	Temp	_____________
Race	_____________	Weight	_____________	Resp	_____________
Pulse: Resting	_____________	2 min. after exercise		_____________