Student Medical Form - Florida
German Measles (Rubella)
MEDICAL FORM
Please complete both sides no later than August 1 and return to: Florida Southern College
Student Health Center
111 Lake Hollingsworth Dr.
Lakeland, FL 33801-5698
1. Name (Last) (First) (Middle) 2. Date of Birth 3. Sex 4. Phone
5. Home Address (Street) (City) (State) (Zip) 6. Student Cell Phone
7. Social Security Number 8. Entrance Date 9.
10. Name of Parent or Guardian (please print)
I authorize medical treatment for myself by the Health
Services of FSC. (If student is under the age of 18,
parental permission is given for medical treatment.)
Please print in ink or type
12. Medical History (note in detail any signicant history) Use reverse side if needed.
Hepatitis B #1 #2 #3
Required For Resident Students and Suggested For Commuting Students
13. Blood Pressure
11. Give Dates IMMUNIZATION RECORD - Required
18. Clinical Evaluation (check each item in the appropriate column) N = normal A = abnormal
1. Nutritional
2. Skin/Nails
3. Head/Face
4. Eyes/Vision
5. Ears/Hearing
6. Nose/Sinuses
7. Mouth/Throat
8. Lymph Nodes
9. Heart
10. Lungs
11. Breasts
12. Abdomen
13. Vascular System
14. Endocrine
15. Neurologic
16. Spine
17. Upper Extremities
18. Lower Extremities
19. Geritourinary
20. Rectum
21. Psychological
N A
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N A
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19. Describe every abnormality in detail (use reverse side if necessary).
20. Describe any current treatment - please include all medications
21. Physical Restrictions or Limitations
Date
Phone Address (Street) (City) (State) (Zip)
Printed Name of Physician
Signature
17. Drug Sensitivity16. Weight 15. Height
14. Pulse
Other
Meningitis
Last Tetanus Booster
Polio
Mumps
DPT
Measles (Rubeola)
N A
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Parent/Student Signature:
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