PHYSICIANS CERTIFICATE OF HEALTH

(To be completed in English by a licensed physician)

Dear Doctor: The following complete health examination and laboratory tests are required for admission into the International Student Program at Columbia College.

Name of student: _____________________________________________________________________________________

Last First Middle Birth date Nationality

Mailing Address: ____________________________________________________________________________________

Number Street City Code Country

HEALTH EXAMINATION

Height:_________ Weight:_________ Pulse:___________ Blood Pressure:_________/_________

Visual acuity: Right 20/________ Left 20/________ Corrected: Right 20/_________ Left 20/_________

Hearing: ____________________________

Allergies to medicine or food – substance and reaction ______________________________________________________

PHYSICAL FINDINGS (Abnormalities must be explained*):

	Normal	Abnormal		Normal	Abnormal		Normal	Abnormal
Skin			Throat			Abdomen
Head			Neck			Hernias
Eyes			Thyroid			Back
Ears			Chest			Extremities
Nose			Breasts			Genito/Urinary
Mouth			Heart			Rectal
Teeth			Lungs			Glandular
			Endocrine System			Central Nervous System

*Explanation of Abnormalities: ________________________________________________________________________________

__________________________________________________________________________________________________________

ANY EVIDENCE OF THE FOLLOWING CONDITIONS: (Please check and comment**)

	Yes	No		Yes	No		Yes	No
Actinomycosis			Infectious Hepatitis			Ringworm of scalp
Amebiasis			Keratoconjunctivitis			Schistosomiasis
Blastomycosis			Leishmaniasis			Syphilis, infectious stage
Chancroid			Leprosy (Hansen’s Disease)			Trachoma
Fayus			Lymphogranuloma Venereum			Trypanosomiasis
Filariasis			Malaria			Tuberculosis (Pulmonary or extrapulmonary)
Gonorrhea			Mycetoma			Yaws
Granuloma Inguinalo			Paragonimiasis

**Comments: __________________________________________________________________________________________________

_____________________________________________________________________________________________________________

Normal Abnormal ** (Explain below)

LABORATORY FINDINGS: Blood-hematocrit or Hgb _____________________________________________________________

Urinalysis _____________________________________________________________

Stool Specimen (ova and _____________________________________________________________

Parasites) results: _____________________________________________________________

Other (specify test) _____________________________________________________________

** Abnormal results must be explained here: ________________________________________________________________________

____________________________________________________________________________________________________________

Immunizations – give dates: Date TB Tests – give dates and results: Date

Polio (oral or Salk) _______________ Tuberculin Test results ___________________ ______________

Tetanus booster within five years _______________ P.P.D. is recommended __________________ ______________

Diphtheria (Adult) _______________ Chest x-ray results ______________________ ______________

Measles _______________

Mumps _______________

Rubella _______________

Do you consider the applicant able to carry on a full course of study involving long hours of work or study in a college or university?

Yes _______________ No _______________ (“No” must be explained):

____________________________________________________________________________________________________________

Additional Comments: _________________________________________________________________________________________

____________________________________________________________________________________________________________

Name of Doctor (print) _______________________________________________________License No. _____________________

Mailing Address: _____________________________________________________________________________________________

Doctor’s Signature _____________________________________________________________ Date _______________________

SSO 3/04