Participant’s Name: ___________________________                            

 

MEDICAL FORM

TO BE FILLED OUT BY PHYSICIAN

 

Patient Name: _________________________ Phone # ___________________

Medical Insurance Co.: ___________________ Policy # ___________________

 

This examination should be performed within six months of the specified program.

 

Immunization History

___ Normal                    ___ If not normal, please specify: _______________________________

When was your patient’s last tetanus shot? ________________

 

Code: S-Satisfactory                X-Not Satisfactory                    O-Not Examined

Eyes   ____                   Extremities ____            Skin          ____

B.P.    ____                   Glasses      ____           HgbTest    ____             Urinalysis ____

Ears   ____                   Nose           ____           Throat       ____             Teeth       ____

Heart  ____                   Lungs         ____           Abdomen  ____             Hernia      ____

 

Hgt. _____ Wt. _____

Allergy: Please specify:__________________________________________________________

General Appraisal:______________________________________________________________

 

(For Women) Has this person menstruated? _____ If not has she been told about it? _____         If so, is her menstrual history normal?_______________________________________________

 

Recommendations and Restrictions while overseas:

 

Special Diet ___________________________________________________________________

 

Special Medicine (name) _________________________________________________________

 

What is the medication for? _______________________________________________________

 

Strenuous Activity ______________________________________________________________

 

Eating Disorders _______________________________________________________________

 

Behavioral Disorders (please specify) _______________________________________________

 

Other ________________________________________________________________________

 

I have examined this person herein described and have reviewed his/her health history.  It is my opinion that he/she is physically and mentally able to engage in all activities, except as noted above.

 

_________________________                ____________________________           Date________

Physician Name (please print)                 Examining Physician Signature

 

Address ______________________________    City _____________________________

 

State ______ Zip ___________                           Telephone ________________________