PHYSICAL
EXAMINATION--HEALTH CERTIFICATE
(Must be
completed by physician)
Applicant’s Name:
_______________________________________________________ Date: ________________
Home Address:
__________________________________________________________ Phone: _______________
Height: ____________ Weight: __________ Pulse:
_______ B.P. High _____________
Vision: R20/
____ Corrected 20/ ______ Low _________________
L20/ ____ Corrected
20/ ______ Normal _______________
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Previous
Diseases (Please
Check): |
Past
(Date) |
Current |
Comments |
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Asthma |
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Allergies |
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Bronchitis |
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Diabetes |
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Epilepsy |
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Heart
Trouble |
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Migraine |
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Rheumatic
Fever |
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Ulcers |
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Have
you ever been treated for or hospitalized for nervous or emotional condition? |
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Other
serious diseases or operations: |
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Normal |
Abnormal |
Describe
Abnormalities |
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Eyes |
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Ears |
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Nose |
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Throat |
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Chest
& Lungs |
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Heart |
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Abdomen |
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Spine |
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Extremities |
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Lymphatics |
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Neurological |
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State any medicine or drugs
to be used regularly by applicant
List any physical disability
that will prevent student from participating in any form of physical activities
or duties?
In your opinion, is
applicant adaptable to dormitory living?
Does applicant have any
communicable disease that would prevent dormitory living?
Examiner: _____________________________________ Address:
______________________________________
_____________________________________________ Date:
_______________________________________
TO EXAMINING
PHYSICIAN: Please mail this
form to: FREE GOSPEL BIBLE INSTITUTE
PO Box 477 Export, PA 15632
FAX: (724) 327-3419
PHONE: (724) 327-5454 EMAIL:
fgbi@fgbi.org WEB PAGE: www.fgbi.org