HEALTH PHYSICAL FORM - Huntington University

Allergies & Restrictions:
___________________
___________________
______________________
Student Last Name
____________________
Student I.D. #
2303 COLLEGE AVENUE
HUNTINGTON, IN 46750
PH: (260) 359-4072; (260)359-4107
HEALTH PHYSICAL FORM
INSTRUCTIONS:
1. A completed and up-to-date health form is required by H.U. Information is kept confidential.
2. If this form is not completed and/or absent from the Health Services Dept., students will be restricted from classes.
3. The required physical is to be performed and signed off by a physician and is to be done within the last 12 months.
4. DEADLINE DATE: August 01 for Fall Semester and January 15 for Spring Semester.
PERSONAL INFORMATION:
LAST NAME FIRST NAME MIDDLE INITIAL DATE OF BIRTH GENDER
HOME ADDRESS CITY STATE ZIP CODE
HOME PHONE CELL PHONE E-MAIL ADDRESS
MARITAL STATUS: (circle) S M W D SOCIAL SECURITY NUMBER
ENROLLING AS: (circle one) Fresh Soph Junior Senior
IF INTERCOLLEGIATE ATHLETE (please circle): Eligibility Year 1 2 3 4 5 Academic RS Medical RS Sport_______________
Student Athlete Phone:__________________________
IN CASE OF EMERGENCY NOTIFY:
NAME
RELATIONSHIP
ADDRESS CITY STATE ZIP CODE HOME PHONE
WORK PHONE
CELL PHONE
_________________________________________________________________________________________________________________
HEALTH INSURANCE INFORMATION: (Please attach a copy of your primary insurance card, front & back. If enrolling in H.U.
student plan as primary, note this information under insurance company name.)
INSURANCE COMPANY NAME
POLICY MEMBER NAME
POLICY MEMBER S.S. # POLICY MEMBER DATE OF BIRTH GROUP NUMBER
IDENTIFICATION NUMBER INSURANCE COMPANY ADDRESS INS. CO. PHONE NUMBER
NAME OF MEMBERS EMPLOYER EMPLOYER ADDRESS EMPLOYER PHONE NUMBER
1.

CURRENT and PAST MEDICAL HISTORY – Indicate which of the following apply to you:
□ Abdominal pain □ Convulsion/seizure □ General weakness □ Kidney stones □ Pertussis (whooping
□ Aching eyes □ Cough □ Glasses/contacts □ Loss of a digit cough)
□ Anemia □ Curvature of spine □ Gout □ Loss of balance □ Pinched nerve
□ Angina/chest pain □ Deafness □ Hay fever □ Loss of memory □ Pins, screws, plates
□ Anorexia □ Decreased motion □ Headaches □ Loss of sensation □ Pneumonia
□ Apnea □ Deformities □ Hearing loss □ Lyme’s disease □ Pregnancy
□ Appendicitis □ Dental appliances □ Heart attack □ Marfan’s syndrome □ Profuse bleeding
□ Arrhythmia □ Depression □ Heart disease □ Measles □ Rheumatic fever
□ Arthritis □ Diabetic problems □ Heart murmur □ Migraines □ Ringing in ears
□ Asthma attack □ Digestive problems □ Heart problems □ Missing organ pair □ Rubella
□ Back/neck injuries □ Dizziness □ Heat illness □ Mononucleosis □ Shortness of breath
□ Blackouts □ Drug abuse □ Hepatitis □ Motion sickness □ Sickle cell
□ Bladder infection □ Easily bruised □ Hernia □ Mumps □ Skin problems
□ Blindness □ Eating Disorder □ Hypertension □ Nausea/vomiting □ Sore throat
□ Blood disorder □ Emphysema □ Impetigo □ Nerve damage □ Speech impaired
□ Blood in urine □ Epilepsy □ Increased thirst □ Neuro disorder □ Stroke
□ Blurred vision □ Fainting spells □ Influenza □ Nose bleeds □ Trouble breathing
□ Cancer □ Feet problems □ Infrequent periods □ Pacemaker during exercise
□ Change in hunger □ Frequent colds/flu □ Insomnia □ Painful joints □ Tuberculosis
□ Chicken pox □ Frequent urination □ Irregular heartbeat □ Painful urination □ Ulcers
□ Concussion □ Frost bite □ Kidney disease □ Persistent cough □ Weight loss or gain
□ Gas reflux
□ None Apply
Explain all checked boxes with Dates of Treatment:_____________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Medical History Questionnaire
Explain “Yes” answers: Yes No
1. Have you ever been denied/restricted in sports participation for any health reasons?....................................... □ □
Date:
Illness/Condition:
_________________ ___________________________________________________
2. Have you ever sprained, strained, dislocated, fractured, broken or had repeated swelling or other injuries of □ □
any bones or joints?............................................................................................................................................
□ Head □ Neck □Back □Shoulder □Hip □Thigh □Knee
□Shin/Calf □ Ankle □Foot □Elbow □Forearm □Wrist □Hand
Date: Injury: Date Released:
__________________ ____________________________________________________ __________________
__________________ ____________________________________________________ __________________
3. Have you ever been hospitalized for a serious illness or injury?..................................................................... □ □
Date: Illness/Condition: Date Released:
__________________ ____________________________________________________ __________________
__________________ ____________________________________________________ __________________
4. Have you ever had surgery? ………………………………………………………………………………… □ □
Date: Surgeon: Procedure: Date Released
__________________ __________________________ ________________________ __________________
__________________ __________________________ ________________________ __________________
5. Are you presently under a doctor’s care? …………………………………………………………………... □ □
Explain any current illness or pre-existing medical conditions that could affect your participation:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
6. Do you have any allergies? ………………………………………………………………………………… □ □
List all allergies (foods, medicine, bees or stinging insects, latex, iodine and anesthesia reactions):
_______________________________________________________________________________________________
2.

HEALTH HISTORY (continued) Yes No
7. Have you ever passed out during or after exercise? ……………………………………………………….. □ □
8. Have you ever been dizzy during or after exercise? ……………………………………………………….. □ □
9. Have you ever had discomfort, pain or pressure in your chest during or after exercise? ………………….. □ □
10. Do you get more tired than your friends during exercise? ………………………………………………… □ □
11. Have you had a severe viral infection (myocarditis or mononucleosis) within the last year? …………….. □ □
12. Has anyone in your family died of heart problems or a sudden death before age 50? ……………………. □ □
13. Has a physician ever ordered a test (ECG, echocardiogram) on your heart? ……………………………... □ □
14. Is there anyone in your family that has asthma? …………………………………………………………… □ □
15. Have you ever used an inhaler or taken asthma medicine? ………………………………………………… □ □
16. Have you ever been knocked out or unconscious or lost your memory due to a head injury? …………….. □ □
17. Have you ever had numbness, tingling, or weakness in your arms or lets after being hit or falling? ……… □ □
18. Have you ever been unable to move your arms or legs after being hit or falling? …………………………. □ □
19. Do you use any special equipment (pads, braces, neck rolls, eye guards, etc.)? …………………………… □ □
20. Have you had any problems with your eyes or vision? …………………………………………………….. □ □
21. Are you happy with your weight? …………………………………………………………………………... □ □
22. Are you trying to gain or lose weight? ……………………………………………………………………… □ □
23. Has anyone recommended you change your weight or eating habits? ……………………………………… □ □
24. Do you limit or control what you eat? ………………………………………………………………………. □ □
25. Has anyone in your family had Marfan’s syndrome? ……………………………………………………… □ □
26. Have you ever had heat cramps, heat illness or muscle cramps? …………………………………………… □ □
27. Are you missing an eye, kidney, testicle or ovary? ………………………………………………………… □ □
28. Are you currently taking any medications/vitamins/herbal remedies for a particular medical condition? ….. □ □
Medication:
______________________________
Condition:
____________________________________________________
Explain any “Yes” answers to the above questions:___________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
3.

PHYSICIAN’S EXAMINATION FOR ALL STUDENTS
________________________________________________________________
________________________
Last name First name M.I. Date of Birth
Height: __________ in. Weight: __________ lbs. Blood Pressure: __________mmHg Pulse: __________BPM
Vision: Right: __________ Left: __________ Corrected: Contacts / Glasses Eyes: Pupils Reactivity _________
ORTHOPEDIC SCREENING Normal Abnormal Specific Findings
Neck ROM /MMT □ □
Stability □ □
Back ROM /MMT □ □ Hyperextension / Hyperflexion
Stability □ □
Deformity □ □ Scoliosis / Lordosis / Kyphosis / Valsalva
Shoulder ROM /MMT □ □ Impingement
Stability □ □ Subluxation / Dislocation / AC Joint
Elbow / Wrist / Hand ROM /MMT □ □ Hyperextension / Hyperflexion
Stability □ □ Valgus / Varus
Hip / Thigh ROM /MMT □ □ Hyperextension / Hyperflexion
Stability □ □ Subluxation / Dislocation
Knee ROM /MMT □ □ Hyperextension / Hyperflexion
Stability □ □ Valgus / Varus / Ant. Drawer / Post. Drawer
Shin / Ankle / Foot ROM /MMT □ □
Stability □ □ Pronation / Supination / Rigid Flat Feet
Other □ □ Bunions / Corns/ Blisters
Region Normal Abnormal Region Normal Abnormal
Nose & Throat □ □ Abdomen □ □
Dental Status □ □ Tenderness □ □
Pharynx □ □ Masses □ □
Neck / Thyroid □ □ Liver □ □
Ears / Hearing □ □ Spleen □ □
Canals □ □ Kidneys □ □
Skin Condition □ □ Scars □ □
Nails □ □ Genitalia □ □
Hair □ □ Hernia □ □
Chest □ □ Pelvic □ □
Pulmonary □ □ Scrotum / Testes □ □
Breasts □ □ Extremities □ □
Axillary Nodes □ □ Movement □ □
Heart □ □ Arms □ □
Rhythm □ □ Legs □ □
Murmurs □ □ Hands □ □
IMMUNIZATIONS RECORD: THIS SECTION MUST BE COMPLETED AT THE TIME OF THE PHYSICAL. ALL STUDENTS, REGARDLESS OF AGE, MUST HAVE DOCUMENTED
PROOF OF IMMUNIZATIONS. (LIST DATES)
DT/DPT _______________1 st _______________ 2 nd _______________ 3 rd Booster _______________ 1 st _____________ 2 nd ___________
OPV/IPV ______________ 1 st _______________ 2 nd _______________ 3 rd Booster _______________ 1 st
MMR @ 1 yr.: _______________ Booster (kindergarten or 6 th grade): _______________ Tetanus Booster (Effective 7-10 years):_________
TB Test (Mantoux) Current this year for 1 st time students: Date _______________ Date Read _______________ Results____________________
Meningitis vaccine _______________ (This vaccine is required of all 1 st year and transfer students.)
SUGGESTED VACCINES ONLY – (Not Mandatory)
Hepatitis B _______________ 1 st _______________2 nd _______________ 3 rd
Hepatitis A _______________ 1 st _______________ 2 nd
ON THE BASIS OF THIS EXAMINATION, I APPROVE THIS STUDENT’S PARTICIPATION IN: (please circle)
Intercollegiate Sports/Cheerleading with no restrictions: YES NO
Physical Education with no restrictions: YES NO
Intramurals with no restrictions: YES NO
Please note any restrictions or limitations:______________________________________________________________________________
Physician’s Name __________________________________ Address _____________________________________Phone_______________
(As the physician, this student has received the required examination and has received ALL necessary immunizations.)
Physician’s Signature __________________________________________ Date of Exam_______________________________
PLEASE RETURN TO: HUNTINGTON UNIVERSITY, STUDENT DEVELOPMENT
2303 COLLEGE AVENUE, HUNTINGTON, IN 46750 Questions? Call 260-359-4026
4. Revised 3/10

LAST NAME:________________________
FIRST:_______________________
ID#:________________________________
STUDENT AUTHORIZATION FOR RELEASE OF INFORMATION
I,_____________________________, Date of birth_________________, a current student at HUNTINGTON
UNIVERSITY, Huntington, IN, authorize the release of pertinent health/medical-status information--
FROM:
_____ The medical facility presently treating me for THIS PARTICULAR INCIDENT
_____The medical facility treating me for ALL medically-related incidents while I am a
student at Huntington University
_____ Huntington University Health Services Department
TO:
_____My parents/guardians
_____H.U. Student Development personnel involved in my care, i.e. (Dean of Students,
Nurse/Health Services, Counselors, Resident Directors)
_____H.U. Athletic Dept. Trainer
_____Other Athletic Dept. personnel, i.e. coaches
_____My personal physician(s)
_____All of the above
_____Other – specify please:_______________________________________________
PRINTED NAME____________________________
Signature___________________________________
Date____________________
REFUSAL TO SIGN ABOVE AUTHORIZATION
PRINTED NAME____________________________
Signature___________________________________
Date____________________
PLEASE RETURN TO: HUNTINGTON UNIVERSITY, STUDENT DEVELOPMENT
2303 COLLEGE AVENUE, HUNTINGTON, IN 46750
PH: 260/359-4072 FAX: 260/359-4107
Revised 9/10