W trachoma - DOC

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					□ daytime undergraduate    NCKU Student Health Check Form
□ master’s
□ doctorate                                           Date of Examination:
                       Name:           Gender: □Male □Female     Date of Birth:

Attach one 2.5cm x Class: _____ Year: _____ Dept.: _____ College: _____                      Student No.:
2.5 cm upper body
                   Email:                                                                    Tel:( )
photo h e r e .
                                                                                             Mobile Phone:

                       Name of Parent:                    Profession:                        Tel:( )
                                                                                             Mobile Phone:
Home Address:                                             Present Mailing Address:
Medical History: □No, □Hypertension, □Epilepsy, □Hepatitis, □Asthma, □Allergy, □Others______________
                              Examination Record                                        Signature of Examiner
                                                           4. Nutrition:
                                                              Body Fat Percentage:
                                                              __________%




                                                                                                 General Examination
                            3. Chest Circumference: Age 18-30:
 1. Height:            cm      ________________cm 14≦BF%20(M);
 2. Weight:18.5≦BMI<24 Kg      Breathing Difficulty:      17≦BF%24(F)
                               ________________cm
                                                          Age 30 above:
                                                                17≦BF%23(M);
                                                                20≦BF%27(F)
 5. Waist    Circumference: 6. Pulse:
    ________________cm                                          7. Blood Pressure:
                               60≦pulse<100 bpm
    Hip Circumference:                                            <130/<85 mm Hg
   ________________cm          Regular:□Yes □No
 8.Vision: L        (corrected               )   R         (corrected                )


                                                                                                 Eyes
                                                                11. Any Other Eye
 9.Color Vision:                  10. Trachoma:
                                                                Disease:
12.Hearing:    L:                                    R:
                                                                                                 E.N.T

13. Ears:                        14. Nose:                      15. Throat:
               87654321                      12345678
                                                                △=filled        ○=caries
                                                                                                 Teeth




16. Teeth: R:──────── L:────────
                                                                〤=lack          ∮=impacted
               87654321                      12345678
17. Chest:                       Heart:                          Lungs:
                                                                                              (internal)
                                                                                              Examination
                                                                                              Physical




18 .Abdomen:                        Liver:                           Spleen:
19. Skin:                        20. Thyroid Gland:             21. Lymph Glands:
22. Spine:                       23. Extremities:               24.Deformity:
25. Hernia:                  26. Speech and mental state:
27. Chest X-ray: (Date of Examination: _________), Result:                                     X-ray
28. HbsAg: -(Negative)                               29. HbsAb:+(Positive)
30. HAVG: -(Negative)                                31.VDRL: -(Negative)
32.Urine: Protein: -(Negative)Occult blood: -(Negative)Sugar: -(Negative)
                Female: Hb: 13.5≦Hb≦17.0 g/dl; WBC: 3.4≦WBC≦9.1 K/cmm;
                                                                                                 Other Items




                       RBC: 4.24≦RBC≦5.56 M/cmm; PLT: 138.1≦PL≦353.4 K/cmm;
33.Blood                Hct: 39.1≦Hct≦48.9 %; MCV: 82.6≦MCV≦97.4         fl
   Routine      Male: Hb: 11.6≦Hb≦14.8 g/dl;WBC: 3.2≦WBC≦9.2 K/cmm;
                      RBC: 3.73≦RBC≦4.93 M/cmm;PLT: 151≦PL≦366 K/cmm;
                       Hct: 33.8≦Hct≦43.4 %;MCV: 82.7≦MCV≦95.5      fl

34. Total Cholesterol:<200          mg/dl 35. Liver Function: GOT        ≦40 ;GPT ≦55
36. Blood Sugar (AC):<110           mg/dl 37. Uric Acid: ≦6(Female);≦7(Male)mg/dl
38. Triglycerides (TG):<150         mg/dl 39. HDL: >50(Female);>40(Male)mg/dl

				
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posted:7/30/2010
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Description: W trachoma