Long-Termexchangeprogram

District

Long-TermExchangeProgram

MedicalHistoryandExamination

Physician:Thisstudentisconsideringayearabroadasanexchangestudent.Insufficient,inadequate,orimproperinformationaboutmedicationsorpsychiatric,psychological,orothermedicalproblemscouldendangerthestudent’slifewhileoverseas.Allergyinformationisespeciallycrucialtohostfamilyplacementandstudentwell-being.Animmediaterelativeoftheapplicantmaynotcompletetheexaminationorfilloutthisform.

Pleasetypeorprintclearly.Pleasesubmitfourcopiesoftheform,withoriginalsignaturesinblueinkoneachcopy.

Applicant’sFullLegalName / Gender / DateofBirth(e.g.,01/Jan/1999)
MaleFemale
Address—Street
City / State/Province / PostalCode / Country
HomePhone / MobilePhone / E-mail

MedicalHistory

1.Howlonghastheapplicantbeenthepatientofthephysician?
2.Hastheapplicanteverbeendiagnosedwithorreceivedtreatment,attention,oradvicefromaphysicianorotherpractitionerfor:
YesNoYesNo
a.Allergiesn. Liverdisease/hepatitis
b.Anorexia/bulimia/othereatingdisordero. Menstrualdisorders
c.Appendicitisp. Mentaldisorders
d.Arthritisq. Pneumonia
e.Asthmar. Rheumaticfever
f.Bowelproblemss. Seriousheadache/migraine
g.Cancert. Stomachulcer
h.Diabetesu. Typhoidfever
i.Epilepsy/seizuresv. Urinarytractinfection
j.Hearinglossw. Vertigo/dizziness
k.Heartdiseasex. Visualproblems
l.Herniay. Eyeglasses/contactlenses
m.Malaria
3.Hastheapplicant:
a. Hadanysurgicaloperationnotrevealedinquestion2,orgonetoahospital,clinic,dispensary,orsanatoriumforobservation,examination,ortreatmentnotrevealedinquestion2? / YesNo
b. Takenanyprescribedmedicationinthepastsixmonths?
c. Presentedanyhistoryorcurrentevidenceofnervous,emotional,ormentalabnormality,functionalnervousbreakdown,nervousfatigue,depression,suicideattempts,eatingdisorders,orantisocialbehavior?
d. Everusedheroin,cocaine,marijuanaorotherhallucinogens,amphetamines,orotherstreetdrugs?
e. Everreceivedtreatmentfororadviceaboutaproblemwithalcoholordruguse,eitherfromaphysician/otherpractitioneroranorganizationthatassiststhosewhohaveanalcoholordrugproblem?
f. Hadexcessiveweightgainorlossrecently?
g. Sufferedchestpain,wheezing,shortnessofbreath,orfaintingepisodes?
h. Sufferedchronicdiarrhea,vomiting,abdominalpain,orconstipation?
i. Exhibitedchronicskinconditions(e.g.,severeacne,eczema,psoriasis)?
j. Sufferedweaknessofneurologicalormuscularskeletalsystem?
k. Hadanydietaryrestrictions?Ifyes,specifyandnotereason(medical,religious,personalchoice):
Ifyesforanypartsofquestions2and3,pleaseexplain:
Question(e.g.,2e) / Natureandseverityofdisorder,diagnosis,frequencyofattacks,andtreatment / Datesandduration
5.Indicateyearwhentheapplicanthadthefollowinginfectiousdiseases(orindicatethatheorshehasnot):
Measles(rubeola) / Mumps / Hepatitis / Whoopingcough(pertussis)
Rubella(Germanmeasles) / Chickenpox / Scarletfever / Other:
6.Theapplicanthasbeenimmunizedagainstthefollowingdiseases(clearlystatethedatesoflastboosterand dosesreceived):
Immunizationsareaprerequisitetoschoolattendanceinmanylocations.Thehostcountryorschoolmayrequireadditionalimmunizations.
Immunization / NumberofDoses / Dates
(e.g.,01/Jan/2006) / Immunization / NumberofDoses / Dates
(e.g.,01/Jan/2006)
Diphtheria / Measles(rubeola)
Whoopingcough(pertussis) / Polio(Sabin-3ormoreTOPV,Salk-4ormoreIPV)
Tetanus / HepatitisB
Rubella(Germanmeasles) / Other(specify)
Mumps
Additional comments:
7.Tuberculosisscreening:Theapplicantmustpresentevidenceofrecent(within3months)Mantoux/PPDskintest.
Dateofscreening(e.g.,01/Jan/2006)Result/diagnosis:.IfadifferenttestwasadministeredortheapplicantreceivedaBCGvaccine,pleaseexplainmethodsandtreatmentsusedtoobtainscreeningresults:

Physical Examination

Height: / Weight: / BloodPressure:Sys.Dia. / Pulserate/minute:
8.Doestoday’sexaminationshowanyabnormalfindingsfor:
YesNo
HeadandneckEar,nose,throatChest/lungs / Yes No
Heart(murmur,pressure)
Hernias
Lymphnodes/breastsGenitalia / YesNo
Extremities(muscular)SkeletalsystemNeurological / YesNo
Abdomen(mass)Rectal
Skin
Ifyes,pleaseprovidedetailedinformationonaseparatepage(typedorcomputer-generatedwiththeapplicant’sfulllegalnameanddateofbirthatthetopofeachpage).
CERTIFICATION
IcertifythatIholdavalidcurrentlicensetopracticemedicineandamnotanimmediaterelativeofthepatient,andthatIhavepersonallyexaminedtheapplicantandreportedmyfindingsasnotedaboveandtheattachedpage(s)(ifnopagesareattached,pleasecheckhere: ).
Ifindtheapplicant:
Ingoodhealthandnotsufferingfromanymentalormedicalcondition(s)thatwouldprecludeparticipationintheprogramSufferingfrommentalormedicalcondition(s)asnotedinmyreport
Ifindtheapplicantingoodhealthandnotsufferingfromanycondition(s)thatwouldprecludeparticipationinsporting/physicalactivitiesofthe
applicant’schoice.YesNo
Physician’sName(typeorprint) / Signature(inblue ink) / Date(e.g.,01/Jan/2006)
Physician’saddress,phone,andfax(typeorstamp)