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 Mother'sSiblings Children
                                Parents  Parents
 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      (_) Female problem
                                             problem

 (_)Glasses            (_) Anemia        (_) Lung      (_) Penis, testicle problem
                                             problem
                                             Liver,
 (_)Headaches          (_) High          (_) stomach,  (_) Sexually transmitted
                           cholesterol       bowel         disease
                                             problem
                                             Urine,
 (_)Head injury        (_) Diabetes      (_) kidney    (_) AIDS
                                             problem

 (_)Deafness           (_) High blood    (_) Arthritis (_) Other ilness
                           pressure
                                             Bone,
 (_)Dizziness/fainting (_) Heart Problem (_) 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

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

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                                   Page 2

Student Health Center - University of Wisconsin Oshkosh
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Physical Examination Form - International Students

Name__________________________________________________________

Date______________

 Age                     Height                Temp
           _____________        _____________                _____________

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

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