Alabama's Public Liberal Arts University

International Admissions/Records Office

Student's Medical History

This 2 page medical history form must be completed in order to enroll in classes.  Personal medical history is required of all students.  All information is considered confidential.

To Be Completed By Student

Full Name:________________________
Address:_________________________
________________________________
Date of Birth (month/day/year):_________
Social Security Number:______________
Parent/Guardian:_____________________
Address:____________________________
Telephone (in case of emergency) __________________________

Personal Medical History
Check the box if you have had the disease listed:
 __Chicken Pox                 __Diphtheria
 __Measles                        __Mumps
 __Polio                              __Rheumatism
 __Scarlet Fever                __Tuberculosis
 __Whooping Cough
 International (foreign national) students:
 __Yellow Fever              __Malaria
 __Smallpox                    __Typhoid Fever
 __BCG (TB skin test required)

 Plan to enroll at the U of M beginning the following term:
For Year ______    __Fall Term     __Spring Term
   __May Term       __Summer 1    __Summer 2
Insurance Carrier (required):_______________________
Policy Number (required):_________________________
Family Physician:________________________________
Address:_______________________________________
Physician's Office Phone:_________________________

Special Concerns - Check and respond as appropriate
 __Asthma_____________   __Auditory_____________
 __Cerebral Palsy _______   __Diabetes____________
 __Epilepsy ____________   __Heart _______________
 __Kidney _____________    __Ulcers ______________
 __Visual ______________    __Wheel Chair __________
 __Other _______________
 __Allergies (specify):___________________________
 __Injuries (specify):_____________________________
 __Surgery (specify):_____________________________
 __Family illness (specify):________________________
   ___________________________________________________

Authorization
I hereby authorize the University of Montevallo to provide general health care and/or obtain services of and/or advice from a physician of its choice in case of illness or emergency, including any necessary transportation of student for such care. 
I hereby also assume all responsibility for the costs beyond that provided in the Student Health Center or  that is specified under coverage of the semester health fee.  The University reserves the right to contact parents/family where deemed appropriate.  All statements in this medical record are true to the best of my knowledge and belief, and I have no abnormality, limitation, or restriction not mentioned in this record.  Should any change in my health status occur, I understand that Student Health Center should be notified in writing.

Signature* _____________________________________ Date: _________________
                        Parent/Guardian or Student
Relationship to Student:_________________________________________________
*Must have signature before heath services can be rendered                

 

 

 

To Be Completed By Physician
Student's Name:_________________________________ Date of Birth:___________________
                                                                                                               (month/day/year)
Medication Allergies:____________________________________________________________

 VACCINATIONS (INCLUDE DATES ADMINISTERED OR ATTACH COPY OF IMMUNIZATION RECORD IN ENGLISH)

  Measles (required if born in or after 1957)
    First dose:________________________
    Second Dose (required):______________
  Diphtheria:_________________________
  Oral Polio - required __________________
    (booster not necessary)
  Tetanus ___________________________
   (required within five years)

 Tuberculosis Test Results (required)*________________
 (International students must have results in millimeters)
Name of Test:____________________________________
Date of Test:_____________________________________
or Chest x-ray reading: ____________________________
 *Test must have been administered and results verified by either physician or Health Department within the twelve months preceding enrollment at the U of M.

Physician's Assessment

     List Current Medications:

Subjects

Normal

Abnormal

Comments

  
  Eyes        
  Vision        
  Ears        
  Nose        
  Tonsils        
  Teeth        
  Thyroid        
  Cervical Glands        
  Breast        
  Lungs        
  Heart        
  Abdomen        
  Skin        
  Extremities        
  Hemoglobin        
  Blood Pressure        
  Other Physical
  Defects		        

Any restrictions on physical activity?  _____ Yes  ____ No
If yes, please explain and recommend any permitted activity: ___________________________
How long have you known the student? __________________________________________ 
Most recent examination:_________________________________________________________
Other health-related recommendations or restrictions: __________________________________________________________________
On the basis of your examination and knowledge, do you believe the student is physically and emotionally able to participate in a full program of college-level study and related activities? _____ Yes   _____ No

Signature of Physician:  _______________________________________
Address:  _______________________________________
_______________________________________
Office Telephone:  _______________________________________

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