Medical History and Physical Examination Form：病史和体检表.docVIP

Student Health Center Box 7188 Davidson, N.C. 28035-7188 Phone: 704-894-2300 FAX: 704-894-2615 Medical History and Physical Examination Form TO ALL NEW STUDENTS ENTERING DAVIDSON COLLEGE Please complete this required form in its entirety. It must be received by us no later than July 15. Full Name Nickname Expected College Graduation Year Cell Phone Number Date of Birth (month/day/year) Sex E-mail Address Parents Names Home Address Home Phone ( ) Parents Employer Work Phone ( ) Work Phone ( ) HOSPITAL / HEALTH INSURANCE (NAME AND ADDRESS OF COMPANY* * AREA CODE/TELEPHONE NAME OF POLICY HOLDER INSURED’S DATE OF BIRTH EMPLOYER IS THIS AN HMO/PPO/MANAGED CARE PLAN? □ YES □ NO POLICY OR CERTIFICATE # GROUP # Does your insurance require primary care physician authorization for referral to specialists? □ YES □ NO PRIMARY CARE PHYSICIAN PHONE # FAX # NAME OF PERSON TO CONTACT IN CASE OF AN EMERGENCY RELATIONSHIP ADDRESS AREA CODE/TELEPHONE ** Please attach a copy of both the front and back of insurance card. Return to: Student Health Center, Box 7188, Davidson, N.C. 28035-7188 1 GUIDELINES FOR COMPLETING IMMUNIZATION RECORD IMPORTANT--The immunization requirements must be met or, in accordance with N.C. law, you will be withdrawn from classes without credit. Acceptable records of your immunizations may be obtained from any of the following: (Be certain that your name and Social Security l ID Number appear on each sheet and that all forms are mailed together. The records must be in black ink and the dates of vaccine administration must include the month, day, and year. Keep a copy for your records.) ? High School Records--These may contain some, but not all of your immunization information. Contact Student Health for help if needed. ? Personal Shot Records--Must be certified by a doctors stamp or signature or by a clinic or health department stamp. ? Local Health Department. ? Military Records or WHO (World Health Organization Document