Practical Writing：Application
for Admission <<BACK
STUDENT
HEALTH CENTER HEALTH BACKGROUND FORM
Name:Guo Donghua
Gender:male
Birth Date: 08 / 08 / 1993
Country of Origin:China
Social Security Number: 427156632
Address:35
Henan Road, Yuexiu District, Guangzhou, PR
China
Phone:85673088
Emergency Contact Name:Guo
Jin
Emergency Contact Phone:38772037
Program of Study at UB:
Computer Science
PART 1: MEDICAL
HISTORY
Self History: (check all that
apply)
Medication(s) taken now or in
the past for this issue? (name/dose)
Family History of this issue?(specify:
Uncle, Mother, etc.)
Alcohol/Drug Problem
Anxiety
Asthma
Cancer
Depression
Diabetes
Eating Disorder
Heart Problem
Hypertension
Neurological Problem
Smoker/tobacco use
Thyroid Disease
Other: Allergy to pollen
Drug Allergy to:
PPD
(Mantoux)(Tine Test Not Accepted)Within the
last 3months unless priorhistory of positive
PPD.*Required if positive PPD
Date Placed: Month/Day/Year
07 / 10 / 2012
Date Read: 48-72 Hours Later
07 / 13 / 2012
Results: Normal
mm in duration
Chest X-Ray Date * 07 / 10 / 2012
Results Normal
If negative CXR and Positive
PPD, was INH offered?
Yes
No
Refused
Was Treatment Given? Explain.
(Length of treatment/months).
TETANUS/DIPTHERIAWithin
10 yrs. (m/d/y)
06 / 15 / 2009
HEPATITIS B(month/day/year)
#1 07 / 10 / 2012
#2 10 / 20 / 2012
#3
VARICELLA(month/day/year)
#1 12 / 10 / 1993
#2
OR Date of Chicken Pox
Disease
MENINGOCOCCAL(month/day/year)
DECLINATIONSTATEMENT(Student
must write namesof declined vaccines &
sign)
I have been provided with information
(risks/benefits/etc.) on the vaccine(s) I
am refusing.
Name(s) of declined vaccine(s): Student
Signature: Guo Donghua
PART 3: PHYSICAL
EXAMINATION
Height: 1.8 m
Weight:70 kg
Blood Pressure: 110/70
Pulse: 65
Please describe both any significant findings
on PE as well as recommendations for care
of student: Excellent Health
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