92 Western Avenue
Fairfield, ME 04937
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Kennebec Valley Community College 92 Western Avenue Fairfield, ME 04937 |
HEALTH CERTIFICATION FORM
Every new student must present a health certification form signed by a Health Care Professional. The student should fill out the Medical History section before taking the form to the Health Care Professional for their medical examination. The completed form must be returned to the Admissions Office.
To be completed by the student:
Personal Health History
|
Date of this report |
_________________ |
Name of Student |
________________ |
|
Address |
_________________ |
Date of Birth |
________________ |
|
Weight |
_________________ |
Height |
________________ |
Medical History of Student
| Do you have any chronic health problems such as: |
Yes |
No | |
|
1. Any hoarseness, cough, or shortness of breath on moderate exertion? |
|||
| 2. Tuberculosis? | |||
| Type____________________________ | |||
| Currently under treatment? | |||
| 3. Epilepsy? | |||
| Any Mental Disorder | |||
| Emotional Instability? | |||
| Headaches (Including Migraine) | |||
| 4. Rheumatism or Rheumatic Fever | |||
| 5. Heart Disease | |||
| 6. Hay Fever, Asthma or Eczema | |||
| Any allergic reaction to drugs? | |||
| Please specify_______________________________ |
| 7. Childhood Infectious Diseases:______________________________________ |
| ________________________________________________________________ |
| 8. Other diseases and conditions:______________________________________ |
| ________________________________________________________________ |
| 9. Operations: (including tonsillectomy, appendectomy)______________________ |
| ________________________________ |
Health Care Professional'S REPORT
It is essential that this report be complete and accurate since no physical examination is given at the school.
| Student's Name:___________________________________________________ |
| Date of Exam:_____________________________________________________ |
| Examiner: (Please Print)______________________________________________ |
| Health Care Professional's Signature________________________________________________ |
| Health Care Professional's Telephone_______________________________________________ |
| How long and in what capacity have you known this student/patient?____________ |
| Yes | No | ||
| Has the student had any serious illness in the last 12 months? | |||
| If yes, give details._______________________________________ | |||
| Has the student ever been restricted as to the amount of exercise? | |||
| Does the student appear to be in good physical and mental health? | |||
| Eyes: Normal vision and eye grounds? | |||
| Glasses worn or required? | |||
| Nose and throat: Clear? | |||
| Teeth: Good condition? | |||
| Gums: Good condition? | |||
| Mouth: Good condition? | |||
| Lungs: Normal to P. & A? | |||
| Heart: Rate__________1 minute | |||
| Is the blood pressure normal? | |||
| S_________________D___________ | |||
| Is there a murmur? | |||
| Evidence of sensitivity to drugs, serum, or medicines? | |||
| State sensitivity____________________________________________ | |||
| Is there any pathology in the abdomen? | |||
| If yes, what______________________________________________ | |||
| Is there a hernia? | |||
| If yes, type_______________________________________________ | |||
| Are there back problems? | |||
| If yes, explain_____________________________________________ | |||
| Muscular Skeletal System. Conditions that would interfere with ability to function. | |||
| Back strain or injury? | |||
| Postural deviations? | |||
| Joint defects? | |||
| Arches normal? | |||
| Neurological Exam. Essentially negative? |