PHYSICAL EXAMINATION - Dance

PHYSICAL EXAMINATION
Please answer each item carefully and accurately to assure a medically meaningful document. The information is strictly
confidential. In order to participate in the program, the CCB – Detroit Summer Intensive at WSU requires you to have a
complete examination.
Name (Last) First MI Soc. Sec. # U.S. Citizen Birth date Sex
Female Male
Permanent Address City State Zip Phone
Person to Notify
In Emergency
Relationship
Address of Above City State Zip Personal Physician Phone
Phone
Will you be covered by a medical Yes No
insurance policy while enrolled?
If yes, name of insurance company
IMMUNIZATIONS: The CCB Detroit Summer Intensive at WSU requires that all students born after 1956 must have had 2 doses of a measles containing
vaccine (rubella, M.R., M.M.R.) prior to registration. One dose must have been after 1980 and at least one of the doses must have been a M.M.R.
Required First Immunization Second Immunization
Vaccine/Type Month Date Year Vaccine/Type Month Date Year
Measles
German Measles
Mumps
Or in lieu of the above: Positive titer date (Rubella) ____/____/____
Positive titer date (Rubella) ____/____/____
Recommended
Polio ____/____/____
Please specify dates
*Tetanus ____/____/____
*A tetanus booster or basic series within the past 6 years is recommended for admission
Hepatitis B (3 shots) ____/____/____ ____/____/____ ____/____/____
1 st 2 nd 3 rd
TB Skin Test (PPD) ____/____/____
Results: Positive ______mm / Negative _____
__________________________________________ ___________________ _____________________________________
Physician or Authorized Signature Date License # or Office Stamp
Father
Mother
Sister
Sister
Brother
Brother
Family History
Age Occupation Significant Medical Problems
Physical Exam Page 1 4/8/2011

Have you had allergies to any drugs? (please specify)__________________________________________________
Are you taking any medication (ex. hormones, inhalers, etc.) on a regular basis? (please list)___________________
_____________________________________________________________________________________________
Have you ever had any significant/chronic medical condition(s)? (please specify)____________________________
Have you ever had a serious injury or surgery? (please list)______________________________________________
_____________________________________________________________________________________________
Do you have any illness or medical condition that requires regular treatment or alteration of your manner of living?
_____________________________________________________________________________________________
Is there any other information which could be of assistance?_____________________________________________
Have you had any of the following? Select “yes” or “no” to all questions about your personal medical history and briefly
comment on “yes” answers in the space provided (dates, complications, etc.).
Yes No Yes No
Asthma____________________________________ Repeated Urinary Tract Infections________________________________
Rheumatic Fever_____________________________ High Blood Pressure___________________________________________
Congenital Heart Problems/Disease______________ Abnormal Bleeding Tendency____________________________________
Hepatitis___________________________________ Epilepsy, Convulsions, Seizures__________________________________
Diminished Hearing__________________________ Cancer______________________________________________________
Infectious Mononucleosis______________________ Gastric or Duodenal Ulcer_______________________________________
Gall Bladder or Liver Disease___________________ Tuberculosis_________________________________________________
Diabetes____________________________________ Thyroid Disease______________________________________________
Severe Headaches____________________________
Comments:__________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________
I certify that this information given on this form is true and correct, and I have no abnormality, limitation, or restriction not mentioned on this
document. I understand that any false information, willful or negligent misrepresentation or failure to disclose any requested information could
be sufficient grounds for dismissal from the Summer Intensive. I acknowledge by my signature that I have read and understand these statements
and I hereby authorize the medical professionals of the CCB Detroit Summer Intensive at WSU to treat my child’s medical conditions that appear
indicated to them.
__________________________________________
Signature
_________________________
Date Signed
The following physical exam is highly recommended but is not a requirement
Name_____________________________________ Social Security Number_________________________
Height__________in. Weight____________lbs. Temp.____F Pulse________ BP_________
Laboratory: Hemoglobin or Hemacrit_____________ Urine SP Gr. ___________ Alb. ________ Sugar _______
TB Skin Test: Date_________ Results___________ Name of Test________________
Eyes: Are glasses worn? ___Yes ___ No Is color vision defective? ___Yes ___No
Ears: Is hearing normal? ___ Yes ___ No Are drums intact? ___Yes ___No
Distant Vision: Right 20/___ Corrected to 20/___ Left 20/___ Corrected to 20/___
Near Vision: Right 20/___ Corrected to 20/___ Left 20/___ Corrected to 20/___
(Wearers of contact lenses are advised to have a pair of glasses for alternative use.)
Normal Abnormal Normal Abnormal
Skin__________________________________________ Abdomen__________________________________________
Head, Face, Neck________________________________ Endocrine system____________________________________
Nose and Sinuses________________________________ Spine______________________________________________
Mouth and Throat________________________________ Neurologic_________________________________________
Teeth__________________________________________ Hernia_____________________________________________
Lungs and Chest_________________________________ Genitalia___________________________________________
Heart__________________________________________ Breasts_____________________________________________
Vascular_______________________________________ Pelvic, if indicated____________________________________
Are muscle strength and function of extremities normal and all digits present? ____Yes ____No
Comments:___________________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________
____________________________________________
Signature of M.D./O.D.
Date
Physical Exam Page 2 4/8/2011