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Johnson C.Smith University
Health Services Center
Medical Form 
                                       
                                       
STUDENT INFORMATION
TO BE COMPLETED BY STUDENT
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Student ID#:
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Last Name:
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First Name:
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Middle Name:
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Permanent Address:
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City:
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State:
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Zip:
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Parent Mobile Phone:
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Student Mobile Phone:
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Parent Email:
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Student Email:
BIOGRAPHICAL INFORMATION
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Date of Birth
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Gender:

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Marital Status:

 
  
 
  
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Classification



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Previously A Patient

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Previously Enrolled:

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Entering Semester:
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Year:
HOSPITAL/HEALTH INSURANCE
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Insureance Company:
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Name of Policy Holder:
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Policy Number:
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Phone Number
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Group Number
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Is this an HMO/PPO/Managed Care Plan?

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Employer:
 
  
 
  
 
  
EMERGENCY CONTACT
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Last Name:
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First Name:
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Middle Name:
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Relationship:
 
  
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Address:
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City:
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State:
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Zip
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Phone:

The following health history is confidential, does not affect your admission status and, except in an emergency situation or by court order, will not be released without your written permission.  Please attach additional sheets for any items that require further explanation.

FAMILY & PERSONAL HEALTH HISTORYTO BE COMPLETED BY STUDENT
Has any person related by blood, had any of the following:
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High Blood Pressure:

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Stroke:

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Heart Attack before age 55:

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Blood or Clotting disorder:

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Cholesterol or Blood Fat Disorder:

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Diabetes:

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Glaucoma:

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Cancer:

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Alcohol/Drug Problems:

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Physchiatric Illness:

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Suicide:

 
  

Have YOU ever had or have YOU now: (please check all that apply)

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High Blood Pressure:

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Allergy Injection/Therapy:

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Anemia or Sickle Cell Anemia:

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Severe Menstrual Cramps:

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Rheumatic:

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Concussion:

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Jaundice:

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Drug Use:

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Stomach Ulcer:

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Heart Trobule:

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Hepatitis:

Alcohol Use:

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Pain/Pressure in Chest:

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Excessive worry or anxiety:

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Severe Head Injury:

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Sexual Transmitted Dx.:

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Migraine Headache(s):

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Shortness of Breath:

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Depression:

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Anorexia:

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Asthma:

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Intestinal Trouble:

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Broken Bone:

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Bulimia

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Pneumonia:

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Frequent Vomiting:

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Eye Trouble - Other than needing glasses: 

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Blood Transfusion:

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Chronic Cough:

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Back Injury:

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Kidney Infection:

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Tuberculosis:

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Head/Neck radiation treatments

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Dizziness or Fainting Spells: 

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Gall Bladder Trouble or Gallstones:

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Smoke 1+ pack cigarettes/week:

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Tumor or Cancer:

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Neck Injury:

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Bladder Infection:

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Wear Seat Belt:

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Diabetes:

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Kidney Stone:

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Knee Problems:

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Exercise Reguarly:

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Mononucleosis:

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Hemia:

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Sinusitis: 

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Hay Fever:

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Hearing Loss:

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Irregular Periods:

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"Pink Eye":

 
  

Check each item YES or NO.  Every item checked YES must be fully explained in the space on the right.

Have you ever experienced adverse reactions (hypersensitivities, allergies, upset stomach, rash, hives, etc.) to any of the following?  If yes please explain fully the type of reaction, your age when the reaction occurred, and if the experience has occurred more than once. 

ADVERSE REACTIONS TO
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Penicillin:

Explanation:
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Sulfa:

Explanation:
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Other Antibiotics (Please Name):

Explanation:
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Aspirin:

Explanation:
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Codeine or Other Pain Relievers:

Explanation:
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Other drugs, medicines, chemicals (specify):

Explanation:
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Insect Bites:

Explanation:
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Food Allergies (Please Name):

Explanation:
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Do you any conditions or disabilities that limit your physical activities?(Please describe):

Explanation:
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Have you ever been a patient in any type of hospital?(Specify):

Explanation:
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Has your academic career been interrupted due to physical or emontional problems? (Please Explain):

Explanation:
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Is there loss or seriously impaired function of any paired organs?(Please Describe):

Explanation:
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Other than for a routine check-up, have you seen a physician or healthcare professional in the past six months?(Please Describe):

Explanation:
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Have you ever had any serious illness or injuries other than those already noted?(Specify):

Explanation:
PHYSICAL EXAMINATION

THE BELOW FORM MUST BE DOWNLOADED & COMPLETED BY THE PHYSICIAN/NURSE PRACTITIONER/PHYSICIAN ASSISTANT

Once have completed the form please return to this application to upload your document. Your progress will be saved. Once you have uploaded the document the Health Services Center will verify that all required information has been attached. Once verified your application will be confirmed and processed. 
Download this form and take it to your physician when doing your physical so that they can fill it out.
 
 
PHYSICAL EXAMINATION FORM UPLOAD
For additional help in obtaining the required information, please contact your primary care physician, school or the Local Health Department in your area. 
 
All records must be completed by July 1st for Fall Enrollment or November 30th for Spring Enrollment.  If you have any questions regarding the information that has been requested from you please contact the Health Services Center at (704) 378 - 1075 - Fax (704) 378 -3530.
 
Thank you for your cooperation in this matter and for choosing Johnson C. Smith University as your institution for higher learning. 
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Check all the required vaccinations that you have completed (this should be what is represented on the form you upload):

Please upload the entire document you downloaded and had filled out by your physician. 
No file selected