2 食物 是 否 C. Hay Fever 花粉热 是 否 D. Insect stings/bites 昆虫叮咬 是 否 E. Penicillin 青霉素 是 否 F. Other medications or allergies (if yes, please list below) 其他治疗

Transcription

1 1 美国 GSA 高中联盟 Medical Information/Health Examination Form 医疗信息及健康体检表 This form must be completed in English by a medical doctor prior to your arrival in the U.S. 该表必须在到达美国之前由一位医生以英文填写 Part I: Student Information (to be completed by student) 第一部分 : 学生信息 ( 由学生填写 ) Student s Full Legal Name 学生姓名 Date of Birth (Month/Day/Year) 出生日期 ( 月 / 日 / 年 ) Gender 性别 Grade Level 在校年级 Home Address 家庭地址 Home Phone 家庭电话 Cell Phone 手机 Part II: Medical History (to be completed by physician/medical doctor in consultation with student and his/her parent/s) 第二部分 : 病史 ( 询问学生和家长后由医生填写 ) Physician, this student has been accepted to a high school in the U.S. Insufficient information about the student s medical history or condition/s could endanger the student s life while overseas. Allergy information is critical to host family placement and the student s well-being. A relative of the student may not complete the examination or fill out this form. 医生 : 该学生已经被一所美国中学录取 为保证该学生在海外得到恰当的医疗, 我们需要收集足够的信息 对于住宿家庭和学生自身而言, 有关过敏症的信息尤其重要 学生的体检和该表的填写应该交由与学生没有亲属关系的医生完成 1. Has the student ever been diagnosed with or received treatment, attention, or advice from a physician for any of the allergies listed below? 在以下所列方面, 学生之前是否被诊断或者接受过医生的治疗或指导? A. Aspirin or any over the counter pain reliever 阿司匹林或任何非处方止痛药是否 B. Food

2 2 食物 是 否 C. Hay Fever 花粉热 是 否 D. Insect stings/bites 昆虫叮咬 是 否 E. Penicillin 青霉素 是 否 F. Other medications or allergies (if yes, please list below) 其他治疗或过敏症 ( 如果有, 请在下方列出 ) G. Does the student carry an epinephrine auto-injector (EpiPen)? 学生带有肾上腺素注射器吗? 是否 2. Has the student ever been diagnosed with or received treatment, attention, or advice from a physician or other practitioner for any of the following: 在以下所列方面, 学生之前是否被诊断或者接受过医生的治疗或指导? Anorexia/bulimia/eating disorder 厌食症 / 易饿症 / 饮食紊乱是否 Appendicitis 阑尾炎是否 Has the student s appendix been removed? 阑尾切除了吗? 是否 Arthritis 关节炎是否 Asthma 哮喘是否 Autoimmune disease 自体免疫疾病是否 Birth defects 出生缺陷是否 Blood or endocrine system disorders 血液或内分泌系统紊乱是否 Bones, joints, scoliosis 骨骼 关节 脊柱是否 Bowel 肠是否 Brain or nervous system 大脑或神经系统是否 Cancer 癌症是否 Cough (persistent) 长期咳嗽是否 Dental 牙齿是否 Braces, retainer, or other? 牙套 固定器 或者其他? 是否

3 3 Depression 抑郁症是否 Developmental delay 发育迟缓是否 Diabetes 高血糖是否 Digestive system 消化系统是否 Dizziness or chest pain with exercise 眩晕或运动时胸部疼痛是否 Ears or hearing 耳朵或听力是否 Eyes or vision 眼睛或视力是否 Does the student wear corrective eyeglasses/contact lenses? 学生佩戴眼镜或者隐形眼镜吗? 是否 Epilepsy 癫痫是否 Genitourinary system 泌尿生殖系统是否 Headaches/migraines 头疼或偏头痛是否 Heart disease 心脏病是否 Heart murmur 心脏杂音是否 Hernia 疝气是否 Hypertension 高血压是否 Impaired organs or loss of function 受损的器官或者失去功能器官是否 Liver disease/hepatitis 肝病或肝炎是否 Lungs 肺是否 Malaria 疟疾是否 Menstrual disorders 月经失调是否 Mental or emotional disorders 精神或情绪紊乱是否 Pneumonia 肺炎是否 Rheumatic fever 风湿热是否 Scarlet fever 猩红热是否 Seizures 心脑血管病是否

4 4 Skin 皮肤是否 Tonsils, nose, throat 扁桃体 鼻 喉是否 Tuberculosis (TB) 肺结核是否 Typhoid fever 伤寒热是否 Vertigo/dizziness 眩晕是否 Other 其他是否 For any of the questions answered yes, please explain below the nature of the disorder as well as the severity, frequency, treatment, and duration. 如果存在以上任何一项, 请在下面详细给出疾病的原因 严重程度 发病的频率 采取的治疗 以及发病时间长度 3. Has the student had any surgical operations or health conditions not listed above? 学生是否动过手术或者有任何在上面没有列出的疾病? 是 否 4. Has the student taken any prescribed medication in the past 6 months? 在过去的六个月里, 学生是否服用过处方药? 是 否 5. Has the student ever received treatment or advice about a problem with alcohol or drug use? 学生是否在一个与酗酒或滥用毒品方面上的问题否接受过治疗或者医生的指导? 是 否 For any of the questions answered yes, please explain below the nature of the condition, treatment, etc. 如果存在以上任何一项, 请在下面详细给出病症的性质 采取的治疗等等

5 5 6. Please list any prescribed medication that the student will be bringing to the country where he/she will be studying. 请列出任何学生将带到就学国家的处方类药物 Name of Medication 药物名称 Dose/Frequency 剂量 / 服用频率 Reason for Use 服用的原因 Part III: Immunization Record (to be completed by physician/medical doctor) 第三部分 : 免疫接种记录 ( 由医生填写 ) Immunization Requirements for Entrance into a U.S. High School 进入美国学校的免疫要求 5 Doses of DTP/DTap ( 五针 DTP/DTap ) 1 Dose of Tdap Tetanus, Diphtheria, and Acellular Pertussis ( 一针破伤风, 白喉, 百日咳疫苗 ) 4 Doses of IPV/OPV ( 四针 IPV/OPV 疫苗 ) 2 Doses of Measles, 2 doses of Mumps, 2 doses of Rubella ( 两针麻疹疫苗, 二针腮腺炎疫苗, 二针风疹疫苗 ) 3 Doses of Hepatitis B ( 三针 B 型肝炎疫苗 ) 2 Doses of Varicella ( 两针水痘疫苗 ) 1 Dose of Meningitis ( 一针脑膜炎疫苗 ) If entering into 12 th grade, a second dose of Meningitis is required. 如果进入 12 年级, 则要求第二针脑膜炎疫苗 Physician, please fill in dates of immunizations below. Include month/day/year immunization was administered. 医生 : 请填写免疫接种的日期, 包括接种的月 / 日 / 年 Immunization 免疫接种 Diphtheria and Tetanus (DTaP, DTP,Td, or DT) 白喉和破伤风 Tetanus, Diphtheria, and Acellular Pertussis (Tdap) 破伤风, 白喉 百日咳 Polio (OPV or IPV) 小儿麻痹症 Hepatitis B 乙肝 Dose 1 第 1 针 Dose 2 第 2 针 Dose 3 第 3 针 Dose 4 第 4 针 Dose 5 第 5 针

6 6 Measles-Mumps- Rubella (MMR) 麻疹腮腺炎风疹混合疫苗 Varicella (Chickenpox) 水痘 Meningococcal (MCV) 脑膜炎 Other 其他 Part IV: Physical Examination (to be completed by physician/medical doctor) 第四部分 : 健康体检 ( 由医生完成 ) Age 年龄 Height 身高 Weight 体重 Blood Pressure 血压 BMI Is the student at risk for diabetes? 学生是否有患糖尿病的风险? 身体质量指数 Are reflexes normal for: 以下方面条件发射正常吗? Pupils 瞳孔是否 Knees 膝是否 Other (please specify) 其他 ( 请说明 ) 是否 Tuberculosis (TB) Skin or Blood Test 肺结核 (TB) 皮肤或血液检测 Skin Test 皮试 Date Read 检测日期 Result (positive or negative) 结果 ( 阳性或阴性 ) Measurement 数值 Blood Test 血液检测 Date Read 检测日期 Result (positive or negative) 结果 ( 阳性或阴性 ) Value 数值 If the results were positive, was a chest x-ray performed? 如果结果是阳性, 是否进行了 X 光透视检查? Date of chest x-ray: 胸部 X 光检查日期 : If the results were positive, was treatment administered? Please elaborate below: 如果结果是阳性, 是否采取了治疗措施? 请在以下详述 : Were there any abnormalities found during the exam? 在体检中是否还发现有任何不正常? 是 否 If yes, please elaborate below: 如果是, 请在以下详述 :

7 7 Part V: Certification (to be completed by physician/medical doctor) 第四部分 : 证明 ( 由医生完成 ) I certify that I hold a valid current license to practice medicine. 我确认我具有合格有效的医师执业证书 Please check one: 请选择以下一项 : The student is in good health and is not suffering from any health conditions, mental or other, that would preclude studying in another country as an international student. 学生身体健康良好, 目前没有任何身体健康疾病 精神疾病, 或者其他会影响其作为国际学生在其他国家学习的疾病 The student is not in good health and is suffering from a health condition that would preclude studying in another country as an international student. 学生健康状况不佳, 在这种身体健康状态下不能够在其他国家作为国际生学习 Comments/Notes 说明 : Physician s Name 医生姓名 : Physician s Signature 医生签字 : Date 日期 : Name and Address of Medical Facility 医院的名称和地址 : Phone Number 电话号码 : 电子邮件地址 :