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WHEATON COLLEGE STUDENT HEALTH SERVICESMEDICAL HISTORY REPORTSEE LAST PAGE FOR INSTRUCTIONS. To be completed by Wheaton College Student; all information must be in English.Name:ID#Last nameFirst nameMIPreferred nameAddress:StreetDate of Entry:/MoCityDate of Birth:Yr/Mo DayStateSex: M/Student’s cell phoneZip FYrMaiden NameStatus: Part-time Full-time Graduate Undergraduate Consortium Modular ELIC Spouse of student EmployeeCampus: Wheaton College HoneyRock/Northwoods Science Station Black HillsHave you previously attended Wheaton College? Yes No If yes, last yearof attendanceIn case of Emergency Notify:(Minors must fill this outwith guardian in the USA)NameState ofHealthMaiden NameAddressHome Phone (with area code)FAMILY HISTORYAge Study Abroad ProgramOccupationAge ofDeathFatherMotherRelationship to studentCell Phone (with area code)Cause of DeathWork Phone (with area code)Immediate Family MedicalHistoryYesNoRelationshipAutoimmune diseaseCancerDiabetesHeart DiseaseKidney l healthdiseaseFamily history of sudden deathbefore age 50 (cause unknown)SiblingsSpouseChildrenPERSONAL HISTORY: Please comment on all yes answers in comment section or on an additional sheet.Have You Had?Y NY enstrual problemsAsperger SyndromeDisordered EatingMononucleosisAsthmaEye problemOrthopaedicBack ProblemGallbladder diseasePneumoniaBipolar DisorderHead injuryPOTSBronchitis, recurrentHeadache, recurrentPTSDCancerHeart condition/MurmurRecent International TravelCeliac DiseaseHepatitisRecurrent ConcussionsChickenpoxHigh Blood PressureSeizuresCounselingHIV/AIDSSelf HarmCrohn’s/Ulcerative ColitisKidney disorderSexually transmitted diseaseNYNSinus conditionSleep DisturbanceStomach DisorderStrep throat, oid disorderTuberculosisUrinary tract infectionWeight gain/loss, recentCOMMENTS:HOSPITALIZATIONS/SURGERY: NoneReason(s)Date(s)List allergies to medications, foods, pollen, molds, other: NoneList medications/herbals taken regularly: NoneList accessibility needs:Other:Student’s Signature (Required)DatePARENTAL CONSENT: If your student is 18 years of age, please complete the Consent for Minors, found on theSHS websiteWebsite: www.wheaton.edu/shsEmail: Student.Health.Services@wheaton.edu Phone: 630-752-5072 Fax: 630-752-55751

1.2.3.4.Have you ever had a period? Yes/NoAge of Onset?How many periods have you had in the past year?Interval between periods?Duration of periods?Are you on medication for your periods? Yes/NoIf "Yes" name of medication:5. Have you gained or lost more then 10 lbs. in the past year?6. Are you happy with your weight? Yes/NoExplain:7. Are you trying to gain or lose weight? Yes/No8. Has anyone recommended you change your weight or diet? Yes/No9. Do you limit or carefully control what you eat? Yes/No10. Have you ever had discomfort, pain, orpressure in your chest during exercise?11. Does your heart race or skip beats duringexercise?Yes/NoGENERAL MEDICALStudent Athlete SignatureWebsite: www.wheaton.edu/shsID#:Year:16. Have you ever experienced any of the following:"Burner" or "Stinger"Head injury or concussion/ How Many?"Blacked out"/"Knocked out"Confusion or memory loss due to hit to headSeizures/EpilepsyHospitalization due to a concussion or mild traumatic braininjuryHeadaches with exerciseNumbness, tingling, or weakness in your arms or legs afterfalling or being hitInability to move a limb due to a hit or a fall17. Have you ever had an injury, illness, or surgery (i.e.sprain, strain, tendonitis, fracture, stress fracture, dislocation,etc.) that caused you to miss a practice or game?Yes/No12. Have you ever fainted or passed out during or Yes/Noafter exercise?13. Has a doctor ever ordered a test for yourYes/Noheart? (i.e. EKG, echocardiogram)14. Has a doctor ever told you that you have:High Blood Pressure Yes/NoHigh CholesterolYes/NoHeart MurmurYes/NoHeart InfectionYes/NoAbnormal Heart Beat Yes/NoSickle Cell DiseaseYes/No15. Do you have a family history of the following:Sudden DeathYes/NoDeath under age 50 Yes/NoHeart DiseaseYes/NoHeart AttackYes/NoPassing out/Syncope Yes/NoSickle Cell DiseaseYes/NoHigh Blood Pressure Yes/NoMarfan's SyndromeYes/NoExplain "Yes" answers here (Please number the answer.):CARDIOLOGY QUESTIONS:NEUROLOGICAL QUESTIONS:Sex:ORTHOPEDIC QUESTIONS:FEMALES ONLY:Name:DOB:Wheaton CollegeComplete Only If New Intercollegiate AthleteAthletics Medical HistorySport(s):Cell NoYes/NoYes/NoYes/NoYes/No18. Have you had a bone or joint injury that required x-rays,MRI, CT, surgery, injections, rehabilitation, physical therapy,a brace, a cast, or crutches?19. Have you had any fractures or stress fractures in the past Yes/Notwo years?Circle the following body part(s) that apply to the above threequestions:HeadHandWristNeckChestLower ther Organs:Yes/No20. Have you been told that you have or have you had an xray for atlantoaxial (neck) instability?21. Has a doctor ever denied or restricted your participation Yes/Noin sports for any reason?Yes/No22. Do you have or have you had any of the following? If"Yes" please circle.CancerAsthmaChicken Pox DiabetesHeat IllnessHepatitisHerniaPneumonia UlcersMeaslesMonoHigh/Low Blood SugarBirth DeformitiesRheumatic FeverKidney DiseaseTuberculosisShortness of BreatheHospitalizationSurgeryYes/No23. Are you currently taking any prescription or nonprescription (over-the-counter) medications?Yes/No24. Do you have allergies to medicines, pollens, foods, orstinging insects?Yes/No25. Are you taking supplements?26. Do you cough, wheeze, or have difficulty breathing during Yes/Noor after exercise?Yes/No27. Do you or a family member have a history of asthma orexercise induced bronchospasms?28. Were you born without, missing, or have lost function of Yes/Noan organ (ovary, kidney, eye, testicle, etc.)?Yes/No29. Do you have any skin disorders (herpes, cold sores,rashes, acne, eczema)?Yes/No30. Have you had any chronic medical problems (chronicfatigue, thyroid condition, diabetes, etc.)?31. Do you wear glasses or contacts for athletics?Yes/No32. Have you had any problems with your vision?Yes/NoYes/No33. Do you regularly use braces, pads, mouth guards,assistive devices, neck rolls, goggles, etc.?34. Have you ever received Chiropractic care?Yes/NoDateEmail: Student.Health.Services@wheaton.edu Phone: 630-752-5072 Fax: 630-752-55752

WHEATON COLLEGE, IL MEDICAL EXAMINATION FORMThis form will meet the medical exam requirement for general entrance and athletic participation. The medical examination must be within one yearprior to date of entrance, unless student is an Intercollegiate Athlete, in which case the medical exam must be done 6 months or less prior to start ofsport.TO THE EXAMINING MEDICAL PROVIDER . Please review the student’s medical history, complete the medical examination form, and comment on allabnormal answers. Please add any laboratory diagnostic exams that are age/medical history appropriate.NameWt. MStudent ID #Ht.BMI FDate of BirthPulseB/PPlease use the CDC.gov BMI calc.LMP date:Regular YesVisionCorrected:Uncorrected:R 20/L 20/ NoHow many periods in a year?Medications:Contact Lenses: Yes NoGlasses:Yes NoAllergies:Food Allergies:Clinical EvaluationCheck each item inappropriate column, at right.Enter “N.E.” if not evaluated.NormalAbnormalMusculoskeletal ExamNormalAbnormal(Indicate L/R)1. Appearance2. Skull, Scalp, Face, Neck,ThyroidC-SpineThoracic, Lumbar, Sacral SpineL3. Nose and SinusesRShoulders4. Mouth (tongue, gingivae, teeth)5. Throat and Tonsils6. Ears (Int. and Ext. canals)7. Eyes (pupils, E.O.M.,ElbowsWristsconjunctiva)8. Lungs and ChestHand/Fingers(include Breasts)9. Heart(rhythm, sounds, andMurmurs. Examine in sitting,recumbent, and left recumbentpositions before and afterexercise.)Hips10. Abdomen/Pelvis andViscera (include hernia)Upper Legs11. Endocrine System12. G-U SystemKneesLower Legs(optional for females) males: testes13. SkinAnkles14. Lymphatic GlandsFeet/Toes15. Neuro/PsychOther:Required: Recommendations for physical activity for intercollegiate, intramurals, club sports, travel abroad, general education requirements, internships.(Please complete or student cannot compete/participate):Cleared without restrictionCleared, with recommendations for further evaluation or treatment for:Not Cleared for All Sports Certain Sports:Reason for Non-Clearance:Recommendations:If this student is an intercollegiate athlete, they must acknowledge education of sickle cell screening through blood test, waiver, or consent to testing. For further information,visit NCAA.org. To request a waiver for this test, please contact the Wheaton College Athletic Department at 630-752-5738. Intercollegiate Athletes must complete Medical Examination by a M.D. or D.O per NCAA rules and Wheaton College Athletic Department. M.D., D.O., PA, or NP SignatureDateMedical Providers Name (please print or use stamp):PhoneFax:Address:Website: www.wheaton.edu/shsEmail: Student.Health.Services@wheaton.edu Phone: 630-752-5072 Fax: 630-752-55753

Name:Student ID #Date of Birth:TUBERCULOSIS (TB) SCREENING QUESTIONNAIREStudent: please fill out and submit form to SHS as this is part of your entrance medical requirements, even if youhave not had any prior testing.Prior Testing: No YesHave you had a TB blood test (IGRA)? No YesIf yes, result: Negative PositiveHave you had a TB skin test (PPD)?Please answer questions 1-16 and provide an explanation if theanswer is “YES.”1. Have you ever been told by a doctor or healthcare provider that youhad active TB?2. Have you ever taken medication for TB? Which medication(s)? Whatyear?3. Have you ever had a BCG vaccine for TB? (BCG does not exemptyou from this requirement)4. Have you ever been told by a health care provider that your immunesystem is not working right or that you cannot fight infection? (e.g.immune disorder or illness)Date:If yes, result: Negative PositiveDate:Explanation Y N Y N Y N Y N5. Have you cared for, or lived with, anyone diagnosed with active TBdisease in the past year? Y N6. Have you worked or volunteered in a setting where TB may be morecommon, such as a homeless shelter, nursing home, group home, orprison, in the past year? Y N7. In what country were you born?8. If you were not born in the USA, since what year have you been in the USA?9. Have you lived in any other country for greater than one year?10. Have you traveled outside the USA in the past year? Y NIf yes, where and when? Y NIf yes, please provide the following information.CountryLength of stay (in days/weeks)CountryLength of stay (in days/weeks)CountryLength of stay (in days/weeks)11. Have you received a live vaccine in the past 6 weeks? (e.g. measles,mumps, rubella, chickenpox, or shingles) Y N12. Persistent coughing (3 weeks or more)13. Coughing up blood or bloody sputum14. Night sweats (soak the sheets)15. Unexplained weight loss?16. Unexplained, excessive fatigue?17. Fever of unknown origin? Y N Y N Y N Y N Y N Y NSHS will review this form and reply to your my.wheaton email account if you need an individual plan for further testing or treatment. Treatment mayinclude a PPD skin test(s) or an IGRA blood test. Depending on your individual plan, these services may be available through Student HealthServices.For non-SHS Medical Providers, please use TB SCREENING SUPPLEMENT FOR MEDICAL PROVIDERS (page 6) to provide additional documentation.Website: www.wheaton.edu/shsEmail: Student.Health.Services@wheaton.edu Phone: 630-752-5072 Fax: 630-752-55754