UTICA COLLEGE HEALTH FORM AND PHYSICAL EXAM FOR

UTICA COLLEGE HEALTH FORM AND PHYSICAL EXAM FOR STUDENTS
Due By: August 1 for Fall Admission, January 10 for Spring Admission
Please check one:
Check fill out all that apply:
☐ Fall Semester, Year ___________________
☐ Spring Semester, Year ________________
☐ Summer Semester, Year _______________
☐ Athlete:____________Sport ___________
Major________________________________
Welcome to Utica College. Information on this form is CONFIDENTIAL; it will not be released without the student’s
consent, and it will not affect the admission status.
Attention Athletes: For Student Athletes – physical exam must be dated after April 1 for Fall admission or after August
1 for Spring admission per NCAA. Student-athletes should also include proof of sickle cell testing and results per NCAA
requirements.
Health Insurance Requirements:
All full-time students are required to have health insurance.
REQUIRED PERSONAL INFORMATION
Utica College ID #__________________________________ Birth date (MM-DD-YY) ______–______–________
Last Name ________________________________________ First Name __________________________MI______
Cell Phone_________________ Sex ☐ Male ☐ Female
PERSON TO NOTIFY IN CASE OF EMERGENCY
Name ___________________________________________ Relationship _________________________________
Home Telephone Number____________________________ Business Telephone Number____________________
Cell Phone Number ____________________
AUTHORIZATION TO PROVIDE MEDICAL CARE
I hereby authorize the Student Health Center at Utica College to give medical and minor surgical care to
(Student Name)___________________________________ on his/her request and to arrange for such care as
necessary in the event of emergencies.
___________________________________________
Student Signature (if 18 years or older)
____________________________________________
Parent/Guardian Signature (if student under 18 years)
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MANDATORY HEALTH UPDATE FORM
ALL students are required to complete and return this form to the Student Health Center at Utica College.
Student Name__________________________________________________________D.O.B._____________________
☐ Yes ☐ No Do you have any drug allergies? Specify.____________________________________________________
___________________________________________________________________________________
☐ Yes ☐ No Do you have any allergies to insect stings, foods, latex, or others? Specify.
☐ Yes ☐ No Do you have any family history of medically unexplained or cardiac-caused sudden death under the age
of 50? Please explain. __________________________________________________________________
___________________________________________________________________________________
☐ Yes ☐ No Do you have asthma? Please list medications taken for this condition.
___________________________________________________________________________________
☐ Yes ☐ No Do you have diabetes? Please list medications you are taking for this condition.
___________________________________________________________________________________
☐ Yes ☐ No Do you have hypoglycemia (low blood sugar)?
☐ Yes ☐ No Do you have any loss of paired-organ function (eye, kidney, testicle)?
☐ Yes ☐ No Have you had a previous concussion or loss of consciousness? Please explain.
___________________________________________________________________________________
☐ Yes ☐ No Have you ever fainted (syncope) or had near syncope with exercise?
☐ Yes ☐ No Have you ever had symptoms of exercised-induced bronchospasm?
☐ Yes ☐ No Have you ever had an incident of heart-related illness?
☐ Yes ☐ No Have you had any operations? Is so, please list.
___________________________________________________________________________________
☐ Yes ☐ No Have you had any serious illnesses in the past? If so, please explain.
___________________________________________________________________________________
☐ Yes ☐ No Have you been hospitalized in the last five years? If so, please explain.
___________________________________________________________________________________
☐ Yes ☐ No Are you currently being treated for any chronic condition? If so, please explain.
___________________________________________________________________________________
Please list all medications that you are currently taking.____________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Student Signature _______________________________________________________________ Date ____/____/______
Note to Athletes: Your signature above authorizes the release of this information between the Student Health Center and the
athletic training staff at Utica College.
Please mail this form to: Utica College Student Health Center, 1600 Burrstone Road, Utica, NY 13502
OR Fax to 315-792-3700
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MANDATORY PHYSICAL EXAM FOR FULL-TIME UNDERGRADUATES
Name__________________________________________________________________________________ D.O.B.____/____/______
This section to be completed by health care provider
Exam: Height______________ Weight ______________ B/P ______________ P ___________ BMI __________
Sickle Cell Screen_____________________ Attach Result
√ Check = Normal Circle = N/A Blank = Not Examined
Note Variances, Abnormal or Significant Findings
☐ General: Healthy appearing, in no acute distress
☐ Skin: Warm, pink, dry with no rash or lesions
☐ Head/Face: Normcephalic. Normal hair growth
☐ Eye: Sclera white. PERRLA.
☐ Nose/Sinuses: Sinuses nontender to palpation, nares
☐ Ears: No pain when helix pulled. External canal normal. TM with
light reflex and landmarks present without erythema, injection,
bulging, fluid, retraction, perforation or drainage. No hearing loss.
☐ Pharynx: Good dental hygiene. No tonsilar hypertrophy. No
erythema, swelling, injection, exudate or lesions of palate/pharynx.
Uvula midline.
☐ Neck: Supple with full ROM. No cervical adenopathy. No
thyromegaly.
☐ Respiratory: Respirations easy and nonlabored. Aerates all lobes well.
Lungs clear to auscultation and percussion. No pleural rub heard.
☐ Cardiovascular: Regular S1, S2 without murmur, gallop or run. No
peripheral edema.
☐ Abdomen: Soft, nondistended with active bowel sounds x 4. No
hepatosplenomegaly. No abdominal guarding, rigidity, tenderness or
masses on palpation. No CVA tenderness.
☐ Musculoskeletal: Extremities with full ROM, no varicosities.
☐ Nuerologic: Oriented x 3. Cranial nerves II-XII intact.
☐ Breast: Symmetrical, no masses/lumps, no dimpling, no palpable nodes,
no nipple discharge, no retraction, no tenderness, BSE discussed.
☐ Genitourinary: External genitalia and hair distribution WNL,
inguinal nodes WNL, no urethral lesions or tenderness.
List all current medications _________________________________________________________________________________________
☐ Yes ☐ No Any pertinent physical findings (e.g. heart murmur, etc.) Specify_________________________________________________
☐ Yes ☐ No Any recommendations for limitation of physical activity? Specify ________________________________________________
☐ Yes ☐ No Is this individual under care for a chronic condition or serious illness? If yes, attach letter of recommendations.
☐ Yes ☐ No Any recommendations for special dietary requirements? Specify _________________________________________________
☐ Yes ☐ No Any recommendations for special housing considerations? Specify _______________________________________________
☐ Unrestricted athletic participation ☐ Conditional athletic participation ☐ No participation
☐List further medical evaluation need before participation is allowed ________________________________________________________
Provider’s Signature__________________________________________ MD, NP, PA, DO
Date_________________________________
Address___________________________________________________ Telephone_____________________________________________
City/State/Zip______________________________________________ Fax__________________________________________________
Please mail this completed form to: Utica College Student Health Center, 1600 Burrstone Rd. Utica, NY, 13502 ◆ Phone: 315-792-3094
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Did you know……….
• The Student Health Center is a free service for Utica College Students who have a physical
exam on file.
• Staff: NP, MD, RN, Administrative Assistant
• Visit: www.utica.edu/student/health/ for services offered at the Student Health Center.
• Utica College requires full time students to carry health insurance and offers a
comprehensive plan for students not covered through another source.
• Prescription Medications: If you are taking a medication at home that you will need to
refill at school, plan ahead as to how you will obtain needed refills. ADHD or ADD stimulant medications are not prescribed at the Student Health Center.
• Allergy Injections: Need to bring complete instructions from Allergist along with dated
serums, and date of last injection. First dose must be given at Allergist office.
• New Student Athletes entering (in the):
Fall semester MUST have a PHYSICAL on file dated after April 1st
Spring semester MUST have a PHYSICAL on file dated after August 1st
• Student athletes must have proof of sickle cell testing on file prior to participation per
NCAA
• Good Idea: Bring a health survival kit to help keep you well. Here are a list of suggested
items: Thermometer, cold/cough medication, throat lozenges, pain/fever medicine, allergy medication, band-aids, first aid cream and cortisone cream.
Note: If you wear contact lenses, bring spare pairs and glasses.
Student Health Center
(315) 792-3094
(315)792-3700 (Fax)

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