MidwesternUniversity
Glendale Campus
Office of Student Services
19555 North 59th Avenue
Glendale, AZ85308
623/572-3210
Medical History Questionnaire
Completion of this form, including all printed lab results, is a pre-enrollment requirement.
NAME (LAST,FIRST, M.I.) / HOME E-MAIL / AGEPERMANENT STREET ADDRESS / CITY, STATE, ZIP / FEMALE
MALE
LOCAL STREET ADDRESS / CITY, STATE, ZIP
COUNTRY OF ORIGIN / DATE OF BIRTH / HEIGHT / WEIGHT
DATE / PHONE# / CELL PHONE #
Dear Student:
To provide a safe and healthy environment for the entire MWU community as well as patients, it is important that all students are aware of their health status. All students are required to submit medical documentation to MWU Student Services prior to orientation. MWU Student Services does not perform this pre-enrollment physical, nor does MWU in any way cover the cost of the physical exam or immunization titer tests. Similarly, the student health insurance, which goes into effect after enrollment, does not cover any of the costs associated with the pre-enrollment physical exam. There is a separate form in the introductory packet for data resulting from testing for immunization titer levels.
THIS IS YOUR PRE-MATRICULATION HEALTH RECORD, WHICH IS TO BE COMPLETED, SIGNED BY YOUR HEALTHCARE PROVIDER, AND RETURNED TO STUDENT SERVICES PRIOR TO ORIENTATION. BEFORE SEEING YOUR HEALTHCARE PROVIDER, BE SURE TO CAREFULLY READ THIS ENTIRE DOCUMENT. THIS RECORD WILL BE KEPT IN YOUR PERSONAL STUDENT FILE AND NOT RELEASED WITHOUT YOUR PERMISSION.
THE INFORMATION NEEDED INCLUDES THE FOLLOWING:
1.A medical history section to be filled out by you.
2. A physical examination and questionnaire section for your healthcare provider to complete.
Carefully double check your health record prior to mailing to be sure that it is properly completed. All incomplete recordswill be returned. You will not be cleared to attend class/clinical rotations if these requirements are not complete.
Please call Student Services on the Glendale campus at 623/572-3210 ifyou have any questions.
YEAR OF GRADUATION: ______
PROGRAM:
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ARIZONACollege of Osteopathic Medicine
Student
Intern
Resident
GLENDALECOLLEGE OF PHARMACY
Pharm.D.
COLLEGE OF HEALTH SCIENCES
Biomedical Sciences Occupational Therapy
Cardiovascular SciencePhysical Therapy
Clinical Psychology Physician Assistant
Nurse Anesthesia Podiatric Medicine
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ARIZONACOLLEGE OF DENTAL MEDICINEARIZONACOLLEGE OF OPTOMETRY
Dental Medicine Student. Optometric Medicine Student
.
NAME:______
(Please print clearly)
YOUR PERSONAL HISTORY / 1. had any kind of surgeryY N / 3. had a blood transfusion
Y N
Have you ever:
(Y=Yes N=No)
/ 2. been seriously injuredY N / 4. been advised to restrict
activities due to your health
Y N
If you answered YES to any of the above, please comment below.
Have you ever had: (Y= Yes N=No)
1. Diabetes Mellitus
/Y N
/6. Cancer
/Y N
/11. Asthma
/Y N
2. High Blood Pressure
/Y N
/7. Arthritis
/Y N
/12. Rheumatic Fever
/Y N
3. Tuberculosis
/Y N
/8. Hepatitis
/Y N
/13. Learning Disorder
/Y N
4. Communicable
Disease
/Y N
/9. Epilepsy
/Y N
/14. Debilitating Menstrual
Cycles
/Y N
5. Heart Trouble
/Y N
/10. Fainting Spells/
Dizziness
/Y N
If you answered YES to any of the above, please comment below.Do you wear glasses? Y N
Do you wear contact lenses? Y N
Do you ever use a hearing aid? Y N
Do you take medicine regularly?Y N
List any medications you are presently taking:
Do you smoke? Y NIf so, how much?
Do you drink alcohol? Y NIf so, how much?
/Do you drink alcohol? Yes No How much?
NAME:______
(Please print clearly)
ALLERGIES ( Please List)Food: ______
______
______
Products (i.e., latex, rubber, etc…) ______
______
______
Medications: ______
______
______
EMERGENCY INFORMATIONIn the event of an emergency, I authorize Student Services to contact the following individual(s) for additional medical information and I give my permission for any diagnostic and therapeutic procedures as may be deemed medically necessary.
Your Signature: / Date:
Name of Contact: / Name of Second Contact:
Relationship: / Relationship:
Address: / Address:
Telephone Day: / Evening / Telephone Day: / Evening
All statements on this questionnaire are true to my knowledge; I have no medical problems or health restrictions not mentioned in this record. I also authorize the release of any immunization records for clinical rotations, if necessary.
STUDENT’S SIGNATURE:
PRINT NAME: / DATE:
Please be certain that all questions and signatures are complete and that you have met the requirements for updating immunizations.
NAME OF PATIENT:______
(Please print clearly)
TO THE EXAMINING PHYSICIANPlease review the student/intern/resident’s history and complete the physical form. Please comment on all abnormal findings.
Blood Pressure / Pulse
Check (√) if normal. Explain all abnormalities below.
Skin/scars Thyroid Varicosities Teeth/gums Musculo-skeletal
Lymph glands Extremities Mouth/throat Lungs
Joints Nose/sinuses Chest Abdomen
Head/neck Eyes/Vision Hernia Ears/hearing
Visual Acuity:With GlassesFar-R_____L_____Near-R______L______
Without GlassesFar-R_____L_____Near-R______L______
Notes on Abnormal Findings: ______
TO THE PHYSICIAN:Failure to provide any/all of the above information will render this physical exam INCOMPLETE and result in the student not matriculating.
In my medical opinion, I verify that this applicant is both physically and mentally capable of participating in a full time academic program.
Signature of Examining Physician: / The Student/Intern/Resident has been advised of findingsY N
Print or Type Physician’s Name / Physician’s Phone / Date
Fax#
Physician’s Address
Please return this form to:
MidwesternUniversity
Office of Student Services
19555 North 59th Avenue
Glendale, AZ 85308
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