HEALTH PHYSICAL FORM - Huntington University

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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
Page 1 and 2: Allergies & Restrictions: _________
Page 3: HEALTH HISTORY (continued) Yes No 7

HEALTH PHYSICAL FORM - Huntington University

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