New Student Medical History And Physical Examination Form Page 3
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TUDENT
EDICAL
ISTORY AND
HYSICAL
XAMINATION
Lawrence University Health Services • 711 E. Boldt Way • Appleton, WI 54911‐0599 • Phone: 920‐832‐6574 • Fax: 920‐832‐7488
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HIS NEXT SECTION IS TO BE FILLED OUT BY A HEALTHCARE PROVIDER ONLY
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HIS FORM IS
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HYSICAL
XAMINATION
Name: _________________________________________ Date of birth: _____ /_____ / ______ Date of exam: _____ /_____ / ______
Height: _____ inches
Weight: _____ pounds
Pulse: _____ bpm
BP: ______ /______ ( ______ /______ , ______ /______)
Vision: R20 /______ L 20 /______
Corrected:
Y
N
Pupils: □ equal □ unequal
Hearing: R _____ L _____
MEDICAL
NORMAL
ABNORMAL FINDINGS
INTIALS
Appearance
Eyes/Ears/Nose/Throat
Lymph Nodes
Heart
Pulses
Lungs
Abdomen
Skin
Neurological
Genitalia/Pelvic
(optional)
MUSCULOSKELETAL
NORMAL
ABNORMAL FINDINGS
INITIALS
Neck
Back
Shoulder/Arm
Elbow/Forearm
Wrist/Hand
Hip/Thigh
Knee
Leg/Ankle
Foot
Tuberculosis (TB) Risk Assessment
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1. Does the student have signs or symptoms of active tuberculosis disease?
Yes
No
If YES, proceed with additional evaluation to exclude active tuberculosis disease
including tuberculin skin testing, chest x‐ray, and sputum evaluation as indicated.
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If NO, do you feel a tuberculin skin test is needed?
Yes
No
2. Tuberculin Skin Test (TST)
(TST result should be recorded as actual millimeters (mm) of induration, transverse diameter; if no induration, write “0”.
The TST interpretation should be based on mm of induration as well as risk factors). **
Date given: _____/_____/_____
Date read: _____/_____/_____
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Result: _______mm of induration
**Interpretation:
negative
positive
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