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Student Medical Record

The document outlines the requirements for completing a student medical record at the university, including submitting health forms signed by a physician and undergoing health screenings, with incomplete or abnormal records resulting in holds on registration or access to student services. Students must also provide personal and medical history information as well as records of immunizations to be medically cleared for their program.

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hamsa Rasbieh
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174 views3 pages

Student Medical Record

The document outlines the requirements for completing a student medical record at the university, including submitting health forms signed by a physician and undergoing health screenings, with incomplete or abnormal records resulting in holds on registration or access to student services. Students must also provide personal and medical history information as well as records of immunizations to be medically cleared for their program.

Uploaded by

hamsa Rasbieh
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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STUDENT MEDICAL RECORD

DEPARTMENT OF
COUNSELING & HEALTH

Medical House Decision


DIRECTIONS Complete Health Form: Yes No
Incomplete for:
Dear new student,

Completing this medical form will permit the NDU medical team to offer you better care during your studies at the
university. Every new student will get an assessment of his/her health status prior to admission to NDU. This form
must be completed, signed by the student and his/her personal physician, and submitted before or upon registration.
A completed medical form is vital for the processing of your registration. Students will not be registered
without submitting their medical record to the medical house (MH). Failure in submitting the student medical
record (SMR) prevents students from getting their NDU identification card (ID).

The MH at NDU shall follow up on students with abnormal results of the health assessment and on vaccination:
• To protect the NDU environment and to ensure that all new students are in good physical
and mental health and are at minimal risk of exposure to communicable diseases.
• To make sure that the MH has an initial health assessment for all NDU students.
• To ensure that all students in the medical fields (Medical Laboratory and Nursing)
are immune to Hepatits B, and students in dorms against Meningitis.

All new students shall be screened for positive TST (Tuberculine Skin Test) during pre-registration or registration
period. The nurse at NDU administers the TST screening through a campaign during the pre-registration or
registration period. Two days later, the new student comes to the MH for TST reading. Positive results require further
investigations and an NDU physician’s appointment for follow up.

After that, new students will be medically cleared, may get their IDs and use the MH services for any health reason.
Your health is vitally important and your time is heavily scheduled, therefore the MH offers you medical care on an
open-access, walk-in or appointment basis during your time at NDU.

After the registration period, all SMRs are entered on the electronic medical record of NDU.
Your medical information is strictly confidential and will not be released to anyone without your consent.
In situations where student’s safety is immediately in danger as a result of an important health issue, medical
information may be shared with appropriate persons to ensure adequate medical care.

PERSONAL INFORMATION

Student ID number Major

Family name First name Middle/Father name

Date of birth Place of birth


Nationality 1. 2.
Gender Male Female Marital Status
Email NDU Dorms Yes No

PERSON TO CONTACT IN CASE OF EMERGENCY


Name Relationship
Address
Home phone number Office phone
Mobile Email
MEDICAL INFORMATION
Physical Examination
Height Weight BMI BP Pulse
Other findings
Smoking habit Yes No If yes, please give relevant details
Allergical reactions Yes No If yes, please give relevant details
Blood type A B AB O Rhesus Positive Negative
Hospitalization
Have you ever been hospitalized? Yes No
If yes, please list year(s) and condition(s)
Medication (please include over the counter drugs, herbs or vitamins)
Are you currently on medication? Yes No
If yes, please list the medication(s), dose(s) and number of tablets/day

Insurance company
Name and address Policy number Expiry date

HEALTH HISTORY
Have you ever had or do you have now any medical problem? Yes No If yes please specify:
Anemia Depression
Bleeding disorder Anxiety/panic attack
Cancer Eating disorder
Attention / learning disorder
Hepatitis Alcohol use
Skin rash Drug use
Tuberculosis Epilepsy or convulsion
Varicella (chicken pox) Head injury
Loss of consciousness
Heart murmur Back pain
High or low blood pressure
Kidney problem Ulcer
Rapid or irregular heart beat Arthritis
Asthma Recent weight gain/loss

Vision problem Other, Please give relevant details


Hearing problem

Family History (cardiometabolic diseases, cancer, psychological disorders or others) Yes No


If yes, please specify
RECORDS OF IMMUNIZATIONS
Measles/Mumps/Rubella
1
Yes No Dates
Diphteria/Tetanus/Pertussis
1
Yes No Dates
Polio
1
Yes No Dates
HepatitisB
1
Yes No Dates
Varicella
1
Yes No Dates
or confirmed chicken pox disease Yes No
Meningococcal Vaccine
2
Yes No Date
BCG vaccine Yes No Date
PPD (within the past 12 months) Yes No If yes, specify: Date Diameter
• 1These vaccins are required for all students.
• 2Meningococcal vaccine is required for all students in dorms.

Physician’s Signature and Stamp Date Student’s Signature

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