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　Course 2 > Unit 6 > Practical Writing
Practical Writing: Health Background Report

In the United States, students are normally required to file a Health Background Report (in form or statement) with the university when they are enrolled. It is used solely as an aid to providing health care while they are at the university. The report usually include three major parts: Medical History, Immunization History and Physical Examination. Read and fill in the following health background form as a practice.

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STUDENT HEALTH CENTER HEALTH BACKGROUND FORM

Name: Gender: Birth Date: Country of Origin:
Social Security Number:
 Address:
Phone: Emergency Contact Name: Emergency Contact Phone:
Program of Study at UB:

PART 1: MEDICAL HISTORY

Self History: (check all that apply) Medication(s) taken now or in the past for this issue? (name/dose) Family History of this issue?(specify: Uncle, Mother, etc.)
Alcohol/Drug Problem
Anxiety
Asthma
Cancer
Depression
Diabetes
Eating Disorder
Heart Problem
Hypertension
Neurological Problem
Smoker/tobacco use
Thyroid Disease
Other: Allergy to pollen
Drug Allergy to:
 Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes 		Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

PART 2: IMMUNIZATION HISTORY

Immunization/Test Vaccine Date Month/Day/Year Physician DiagnosedDisease/Date Of Onset Serology Results/DateNote whether immune
MEASLES #1    
#2    
MUMPS      
RUBELLA      
COMBINED ASMMR #1  
#2
PPD (Mantoux)(Tine Test Not Accepted)Within the last 3months unless priorhistory of positive PPD.*Required if positive PPD Date Placed: Month/Day/Year
 Date Read: 48-72 Hours Later

Results:
　　　　　　mm in duration
Chest X-Ray Date * Results
If negative CXR and Positive PPD, was INH offered? Yes No Refused
Was Treatment Given? Explain. (Length of treatment/months).
TETANUS/DIPTHERIAWithin 10 yrs. (m/d/y)  
HEPATITIS B(month/day/year) #1 #2 #3
VARICELLA(month/day/year) #1 #2 OR 　Date of Chicken Pox Disease
MENINGOCOCCAL(month/day/year)      
DECLANATIONSTATEMENT(Student must write namesof declined vaccines & sign) I have been provided with information (risks/benefits/etc.) on the vaccine(s) I am refusing.
Name(s) of declined vaccine(s): 　　　　　　　　　　Student Signature:

PART 3: PHYSICAL EXAMINATION

Height: Weight: Blood Pressure: Pulse:

Please describe both any significant findings on PE as well as recommendations for care of student:

Provider Signature/Address/Phone: Date:

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©Experiencing English（2nd Edition）2007