|
MEDICAL INFORMATION
Student Name: __________________________ Date of Birth: ____ /____ /____MM DD YEAR
PHYSICAL EXAMINATION OF STUDENT
Height_______Weight________________BloodPressure/Type______________Pulse_____________
Visual Acuity Hearing
(Without Correction) R _____ /_____ L _____ /_____ R _____ /_____ L _____ /_____
(With Correction) R _____ /_____ L _____ /_____ R _____ /_____ L _____ /_____
Respiratory System _________________________ Cardiovascular System
Neurological System_________________________Musculoskeletal System
Urinalysis S.B. ___________________Alb ___________________Sugar Micro
E.N.T. Liver _________________ Spleen
Abdomen _______________________Skin __________________Genitals
Allergies? YES NO If yes, please explain:
Students should only bring medications prescribed by their doctor. Please explain clearly, in English, what medications the student needs while on the program:
Is this student physically able to participate in sports? O YES O NO
STUDENT’S MEDICAL HISTORY
Please mark answer yes or no. If you answered “yes”, please explain to the right.
No Yes Explanation
Kidney Disease ____ ____
Congenital anomalies ____ ____
Neurological disorders ____ ____
Eye problems ____ ____
Hospitalization ____ ____
Pulmonary disease ____ ____
Cardiac disease ____ ____
Endocrine disorder ____ ____
Eating disorder ____ ____
Menstrual disorder ____ ____
Orthopedic problems ____ ____
Convulsions ____ ____
Operations ____ ____
Mental disorders ____ ____
ADD or ADHD ____ ____
Depression ____ ____
I, the undersigned, have given a thorough physical examination and reviewed the medical history of this student. I certify that all important medical information has been included, and that the above information is complete and accurate.
Physician’s Signature: __________________________________________________________ Date:
Physician’s Name:
Physician’s Address:
学生体检表
学生姓名： 出生日期：
身高 体重 血压及血型 脉搏
视力 听力
校正前 右眼 / 左眼 / 右耳 / 左耳 /
校正后 右眼 / 左眼 / 右耳 / 左耳 /
呼吸道系统 心脏、心血管系统
神经系统 肌肉骨骼系统
泌尿系统 白蛋白 尿糖 矿物质
耳鼻喉 肝 脾
腹腔 皮肤 生殖器
是否有过敏现象？〇有 〇无 如有，请做进一步解释
该生是否适合参加体育运动？〇适合 〇不适合
在项目期间，学生只能携带医生所开处方药，请详细说明学生需要携带的药物：
学生病史
请用有或无回答下表相关问题，如果回答为有，请做进一步的解释：
无 有 解释
肾病
先天性畸形
神经错乱
眼症
住院史
肺病
心脏病
内分泌失调
饮食失调
月经不调
口腔问题
癫痫
手术史
精神错乱
强迫症
抑郁症
我，下文签名者，已认真研究申请人的病例，并对申请人进行全面体检，特此证明所有重要的体检信息已经在此表上注明，以上信息完整无误。
医师签字： 日期：
医师姓名：
医师地址：
中英文都请加盖医院公章
|
