MEDICAL HISTORY AND PHYSICAL EXAM FORM

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					                                 BENCHMARK YOUNG ADULT SCHOOL
                                               25612 Barton Rd., #286
                                                Loma Linda, CA 92354
                                            909-307-3973 Education Center

                  MEDICAL HISTORY AND PHYSICAL EXAM FORM
Name ________________________________________________________ Student ID# __________
         (Last)                              (First)           (Middle Initial)
Home Address ______________________________________________________________________
                                                                                                                  Male _____
City/State/Zip Code _________________________________________________________________                            Female ____
Home Address of Parents _______________________________________________________
City/Zip Code ______________________________________________________________________
Date of Birth / Place of Birth _________________________________________________________

                                              PART I – MEDICAL HISTORY
This form must be completed by student prior to the physical examination and should be taken with the physical examination
form for review by the physician during the examination.

YES      NO       1.    Have you ever had any of the following? Please explain any YES answers

___      ___      Heart murmur ________________________________________________________________________
___      ___      High blood pressure ____________________________________________________________________
___      ___      Other heart problems ___________________________________________________________________
___      ___      Broken bones _________________________________________________________________________
___      ___      Weak joints-ankles, knees ________________________________________________________________
___      ___      Concussion ___________________________________________________________________________
___      ___      Operation ____________________________________________________________________________
___      ___      Seizures or Epilepsy _____________________________________________________________________

___       ___     2.    Have you ever fainted or passed out? ___________________________________________________
___      ___      3.    Have you ever been knocked out? _____________________________________________________
___      ___      4.    Have you ever been hospitalized? ______________________________________________________
___      ___      5.    Have you ever had to stop running after ¼ to ½ miles for chest pain or shortness of breath? ________
___      ___      6.    A. Have you ever had significant allergies to:
___      ___                Bee stings? - On medication – yes ___ / no ___________________________________________
___      ___                Foods ________________________________________________________________________
___      ___                Medicine ______________________________________________________________________
___      ___                Others ________________________________________________________________________
                        B. Do you have prescription for use of::
___      ___                Adrenaline _____________________________________________________________________
___      ___                Inhalers _______________________________________________________________________
___      ___                Other allergy medicine ____________________________________________________________
___      ___            C. Do you have asthma? ___________________________________________________________
___      ___      7.    Do you take any medicine regularly? _____________________________________________________
___      ___      8.    Have you had any illnesses lasting a week or more such as mononucleosis, etc.? ____________________
___      ___      9.    Have you had any blood disorders, including sickle cell trait, anemia, etc.? ________________________
___      ___      10.   Has any family member had a heart attack, heart problems or sudden death before the age of 50? ______
___      ___      11.   Do you wear contact lenses, eyeglasses or dental appliance? ___________________________________
___      ___      12.   Do you have any missing or non-functioning organs such as testes, eye, kidney, etc.? ________________
                  13.   Menstrual History:
___      ___                Regular periods? Date of onset: ______________________________________________________
___      ___      14.   Do you have any other significant health problems? _________________________________________
___      ___      15.   Hepatitis B Immunization Series? _______________________________________________________
                  16.   DATE OF LAST TETNUS IMMUNIZATION ___________________________________________

Student Signature: ____________________________________________________________________________________

                                                                                                            MedHist 10132005
                                          PART II – PHYSICAL EXAMINATION
                                     (To be completed and signed by examining physician)


NAME: __________________________________________________ SCHOOL: Benchmark Young Adult School

HEIGHT ____________________________ WEIGHT ___________________ SEX _____ AGE _____

Tanner Stage or Maturation Index ____________________________                             BP                  ___________
Percent Body Fat _________________________________________                                Pulse (rest)        ___________
                                                                                          Exercise            ___________
Vision: Corrected __________ (L) __________ (R) Both __________                           Recovery            ___________
Uncorrected (L) (R) Both___________

Audiogram: _____________________________________________                  Cervical spine/neck ________________________
                                                                          Back ____________________________________
Eyes __________________________________________________                   Shoulders ________________________________
Ears __________________________________________________                   Arm/elbow/wrist/hand _____________________
Nose _________________________________________________                    Knees/hips _______________________________
Throat ________________________________________________                   Ankles/feet _______________________________
Teeth _________________________________________________
Skin __________________________________________________                   Lab:
Lymphatic _____________________________________________                   Urine ____________________________________
Lungs _________________________________________________                   Hemoglobin or HCT ________________________
Heart _________________________________________________                   and/or Fe Stores ___________________________
Abdomen ______________________________________________
Genitalia/hernia _________________________________________

I have reviewed the data above, reviewed his/her medical history form and make the following recommendations for his/her
participation in athletics.
        _____ Full Participation _____ Limited Participation _____ No Participation _____ Needs Additional Evaluation

If not full participation, provide reasons & recommendations: ____________________________________________________

Any recommendations or concerns on such items as:
a. Weight loss or gain or restrictions of weight loss: ___________________________________________________________
b. Slow and careful monitoring of conditioning because of being overweight or show an abnormal exercise testing: __________
___________________________________________________________________________________________________
c. Other: ____________________________________________________________________________________________

Physician Signature ___________________________________________________, M.D.                     Date ___________________
*Doctor of Medicine, Doctor of Osteopathy or Licensed Nurse Practitioner

Physician Name (print) _______________________________________________________________________________
Address _____________________________________________________________________________________________
City/State / Zip Code __________________________________________________________________________________
Telephone / Fax Number _______________________________________________________________________________

                                             Please complete and return to:
                                               Benchmark Young Adult School
                                                    Admissions Director
                                                   25612 Barton Rd., #286
                                                   Loma Linda, CA 92354


Student Authorization
I authorize the release of this Physical Examination form to Benchmark Young Adult School. Date: ______________________________

Student’s Name (print) _____________________________ Student’s Signature _______________________________________




                                                                                                         PhysExam 10132005