The Health Examination Report Must Be Completed in Its Entirety by All Resident Students

A completed Health Examination report must submittedby all students with the exception of Domestic Part Time Graduates, IDEAL Students, and Domestic Graduate Education Students, If any portion of this form is found to be incomplete, it will be immediately returned to the student by Student Health Services. Registration at the University cannot be confirmed until this form has been accepted as complete by Student Health Services. Parts A and B should be completed by the student prior to being examined by the physician.

Entering Semester:  Fall  Spring Year: ______Status:  Resident Off Campus Student

University of Bridgeport Student ID ______Email:______

PLEASE

PART C- TO THE PHYSICIAN :
PART C- TO THE PHYSICIAN : THE FOLLOWING IMMUNIZATIONS WITHIN THE BOLD BLACK BOX ARE MANDATORY BY CONNECTICUT STATE LAW PRIOR TO REGISTRATION AND TO RESIDE IN ON-CAMPUS HOUSING
الى الطبيب:اللقاحات او التطعيمات التالية والتي ضمن الاطار الاسود هي لقاحات الزامية حسب قانون ولاية كونكتكت لذا يجب التزود بها حسب القانون قبل التسجيل او السكن داخل الحرم الجامعي.

PART D- TO THE PHYSICIAN (للطبيب)
Please, review the student’s history and complete the Health Examination Report. This information will be used only as background for providing health care and will not be released without the student’s consent.رجاءا الاطلاع على سجل الطالب الصحي وملا الحقول التالية.هذه المعلومات ستستخدم لغرض العناية الصحية للطالب وسوف تتم جميع الجراءات بموافقة الطالب.

I have examined(قد اجريت الفحص ل) ______Date: ______
(LAST) (FIRST) (M.I.) (MONTH) (DAY) (YEAR)
History of Present Illness(تاريخ الاصابة بالامراض مثلا داء السكري او الربو) (i.e., asthma, diabetes): ______
Past Medical History/Surgeries/Injuries/Psychiatric(تاريخ اجراء العمليات الجراحية/الاصابات/النفسية) ______
Social History: (التاريخ الاجتماعي)______
Travel within the past year? (السفر للسنة الاخيرة) Location and Dates(مكان وزمان السفر)______
Family History (i.e., diabetes/hypertension/heart disease/cancer, etc.): (التاريخ العائلي كمرض السكري/ضغط الدم/امراض القلب/السرطان) ______
List ALLERGIES (including medication, insect venom, etc.(هل الطالب متحسس/للعلاجات/او الحشرات) ______
Comment on type of reaction (i.e., rash, urticaria, anaphylaxis):((في حالة وجود حساسة مانوع رد الفعل/حكة/الحساسية المفرطة) ______
List all MEDICATIONS currently being taken(اسماء العلاجات التي يتعاطاها الطالب حاليا في حالة وجودها)______
PHYSICAL EXAM
Weight ______Blood Pressure ______
Height ______Pulse ______Temp. ______
Glasses ______Vision (R) ______(L) ______
Contacts ______Hearing (R) ______(L) ______
General ______Back/Spine ______
Skin ______Extremities ______
HEENT ______Genito/Urinary ______
Neck ______Vascular ______
Lungs ______Lymphatic ______
Heart ______Neurologic ______
Chest ______Abdomen ______
URINALYSIS:
Protein ______Sugar ______Blood ______Other: ______
Laboratory Findings: ______
HGB ______or HCT ______
Any other lab results: ______
Status of Student’s Physical restrictions:  Unrestricted  Partial restriction  Full restriction
Comments: ______
Are there any limitations regarding this student’s participation in school or residing on campus?  Yes  No
If yes, please specify ______
CLINICAL IMPRESSION: ______
Recommendations:______
Print Physician’s Name______Telephone______
Address______
Physican’s Signature:______Date of Exam:______