MEDICAL EXAMINATION FORM - Lake Erie College

MEDICAL EXAMINATION FORMLake Erie CollegeThis form must be filled out, signed by a family physician, and returned to the Student LifeOffice before any student can receive a room key.Full Name:________________________________Date of Birth:____________Height:_____________ Weight:______________ Blood Pressure:___________Past History and Present Conditions (please include dates of past conditions)Childhood Illnesses:_______________________________________________________Accidents/Injuries:________________________________________________________Operations:______________________________________________________________Hospitalizations (including mental health):_____________________________________________________________________________________________________________Illnesses/disorders/dependences:_____________________________________________________________________________________________________________________Please indicate if student requires handicap-accessible facilities and to what extent:_____________________________________________________________________________List any allergies to drugs, food or environmental agents:__________________________________________________________________________________________________Please comment on patient’s current physical status:______________________________________________________________________________________________________Please comment on patient’s current mental status:_______________________________________________________________________________________________________Do you feel that the student is physically able to fully participate in athletic and/orequestrian activities and physical education activities? YES NOIf not, please indicate which limitations on activity the student should exercise:____________________________________________________________________________________________________________________________________Is a single room needed? YES NOIf YES, please indicate reasons:____________________________________________________________________________________________________________________________________________________________________________

List any symptoms and illnesses for which the student requires on-going medical care,including any regular medications:________________________________________________________________________________________________________________________________________________Any additional information or comments relevant to the student’s physical and mental health:__________________________________________________________________________________________________________________________________________________Do you have any hesitations with this student living on a college campus? YES NOIf yes, please list reasons:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________Date of Examination:__________________________Physician’s Name:____________________________Address:_______________________________________________________________________________Telephone: (____)____________________________Physician’s Signature:_____________________________________