大学体验英语(二)

HOME

Listen and Talk

Read and Explore

Write and Produce

Culture Salon

Related Links

Glossary

　Course 2 > Unit 6 > Practical Writing

Reference key:

　　　　Practical Writing：Application for Admission　　　　　　　　　　　　　　　　　　　　　　　 <<BACK

STUDENT HEALTH CENTER HEALTH BACKGROUND FORM

Name:Guo Donghua	Gender:male	Birth Date: 8/8/1983	Country of Origin:China
Social Security Number:335-78-6158	Address:35 Henan Road, Yuexiu District, Guangzhou, PR China
Phone:85673088	Emergency Contact Name:Guo Jin		Emergency Contact Phone:38772037
Program of Study at UB:	Computer Science

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 Claritin/1 tablet per day Yes ________________	Yes ________________ Yes ________________ Yes ________________ Yes ________________ Yes ________________ Yes ________________ Yes ________________ Yes ________________ Yes ________________ Yes ________________ Yes 　Uncl 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 12/10/1983
MEASLES	#2 8/01/84
MUMPS
RUBELLA
COMBINED ASMMR	#1
COMBINED ASMMR	#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 07/10/02	Date Read: 48-72 Hours Later 07/13/02	Results: 　　　　　　　　　　mm in duration
	Chest X-Ray Date * 07/10/02		Results　Normal
	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)	06/10/99
HEPATITIS B(month/day/year)	#1 07/10/02	#2 10/20/02	#3
VARICELLA(month/day/year)	#1 12/10/83	#2	OR 　Date of Chicken Pox Disease
MENINGOCOCCAL(month/day/year)
DECLINATIONSTATEMENT(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: 1.8 m

Weight:70 kg

Blood Pressure: 110/70

Pulse: 65

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

Provider Signature/Address/Phone: Date:
　　　　　　　　　　　　　　　　　　　　　　John Brown 10/10/02