Thomas Brown Rudd Health Center - Hamilton College

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Please complete this form before going to your health care provider for an examination (please print). Family Medical History Adopted ____ Yes ____ No Immediate Family Only Father Mother Brothers Sisters State of Cause Age Health Occupation If Deceased Blood Diseases Cancer Diabetes Seizure Disorder Heart Disease High Blood Pressure Kidney Disease Respiratory Disease Yes Relationship PERSONAL HISTORY: PLEASE ANSWER ALL QUESTIONS. Comment on all positive answers in space below. HAVE YOU HAD Yes No Yes No Yes No ALLERGY TO: Yes No SURGERY: Yes No Acne (on medication) Head Injury Pneumothorax Medications: Appendectomy ADD/ADHD w/Unconsciousness Seizures If yes, please Tonsillectomy Anemia Heart Palpitations/ Sexually specify below Hernia Repair Anxiety/Depression Long QT Syndrome Transmitted Infections Other (describe) Asthma High Blood Pressure Sickle Cell Dis./Trait. Insect Bites Blood/Clotting Disorder Kidney Disease Sinusitis Foods (which) Cancer/Tumor Lyme Disease Sleep Disorders Seasonal Concussion Malaria Stomach or Other (explain) Diabetes Marfans Syndrome Intestinal Trouble Do you currently Disease/Injury of Joints Migraines Suicide Attempts get allergy shots * Eating Disorder Mononucleosis Thyroid Disease Eye Trouble Obsessive Compulsive Tuberculosis Disorder Vision/Hearing Impair. * For allergy shot information please see website: www.hamilton.edu/healthcenter/care for instructions. Explain any yes answers from above: __________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Have you received counseling or been hospitalized for mental health or psychiatric care ___ Yes ___ No If yes, please explain:________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Please list any current medications: prescriptions, over the counter, and herbal medications, including birth control pills:_______________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Any additional pertinent information__________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________
Physical examination is to be completed by your Health care Provider and is required within a year prior to arrival at Hamilton College. ☐ M ☐ F Last Name First name Gender DOB MM DD YYYY Please review the student’s history prior to completing the form below. Students are not eligible to participate in any Hamilton College sports programs, intercollegiate, intramural and club, until this form has been completed and submitted. Students taking Medication for ADD/ADHD will not be able to obtain prescriptions for refills from the Thomas Brown Rudd Health Center. Please make arrangements for refill prescriptions with your patient Height: ___________ Weight (lbs.): _____________ BMI: _________ Blood Pressure: _____ /_____ Pulse: _________ Any allergies to medication(s) / food(s) ____No ____Yes/ Please list:_______________________________________________________ ________________________________________________________________________________ System: Normal / Abnormal. Explain any abnormal System: Normal / Abnormal Explain any abnormal findings: findings: Skin ☐ ☐ Breasts ☐ ☐ HEENT ☐ ☐ Abdomen ☐ ☐ Neck/Thyroid ☐ ☐ Neurologic ☐ ☐ Lymph Nodes ☐ ☐ Extremities/Joints ☐ ☐ Cardiac ☐ ☐ Back ☐ ☐ Lungs/Chest ☐ ☐ Genitourinary ☐ ☐ Tuberculosis Risk Assessment: If a student is high risk for exposure, documentation of a Tuberculin Skin Test (Mantoux) is required within 6 months prior to arrival at Hamilton College. High risk is defined as prior contact with a person with TB; being born, having lived, or traveled in (within 5 years) a high risk region (see list on following page); having lived or worked in a nursing home, prison, mental institution, homeless or HIV setting, or history of injection drug use, HIV infection, diabetes, chronic renal failure, immunosuppression. HX of previous BCG vaccination does not preclude Mantoux testing if indicated. Chest xray required if history of current or previous positive Mantoux, or immunosuppressed. Please see immunization page to record Mantoux, IGRA, and/or chest xray documentation. History of positive Mantoux ☐ No ☐ Yes TB Risk Assessment: ☐ Low Risk ☐ High Risk Currently on any long term medications ___No ___ Yes/What____________________________________________________________ ________________________________________________________________________________ Has physical activity been restricted in the past 2 years _____No_____Yes/Explain:____________________________________________ ________________________________________________________________________________ Recommendations for physical activity (PE, Intramurals, Club, Collegiate): ______Unlimited ______Limited, Explain:______ ________________________________________________________________________________ Has student ever been treated for mental health or behavioral concerns ___No ____Yes/Explain:_________________________________ ________________________________________________________________________________ Health Care Provider Name (Please Print)__________________________________ Health Care Provider Signature:__________________________________________ _______________________ Date of Exam : MM DD YYYY Address _______________________________________________ or Office _______________________________________________ Phone:____________________________ Stamp ________________________________ Fax:______________________________ ________________________________
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Thomas Brown Rudd Health Center - Hamilton College

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