CHAFFEY COLLEGE SCHOOL OF HEALTH SCIENCES HEALTH EXAMINATION FORM

Transcription

1 CHAFFEY COLLEGE SCHOOL OF HEALTH SCIENCES HEALTH EXAMINATION FORM The following student has been accepted in the NURAST Program. Please have your physician complete and return this form prior to attending your first course in Chaffey College's Health Sciences Program. Mr./Miss/Mrs. Birth Date / / Last First MI. Weight Height Pulse Blood Pressure Section I. MEDICAL EXAMINATION: Check each Item in Appropriate Column Normal (Enter NE if not evaluated) HEENT Lungs and chest Breasts Heart (Thrust, size, rhythm, sounds) Vascular system Abdomen and viscera (including hernia) Endocrine system G-U system Upper/Lower extremities (Strength, range of motion) Spine, other musculoskeletal Skin and lymphatic Neurologic (Tendon reflexes, equilibrium, senses, coordination, etc.) Psychiatric (Specify any personality deviation) Abnormal Notes: Describe any abnormality in detail. HEARING Right ear Left ear Whispered Voice (Standing sideways far ear closed) /15 ft. /15 ft. or Audiometer (Decibel loss) DISTANT VISION (Standard test types only) NEAR VISION (Use linear values) Right eye 20/ Corrected to 20/ 20/ Corrected to 20/ Left eye 20/ Corrected to 20/ 20/ Corrected to 20/ Both eyes 20/ Corrected to 20/ 20/ Corrected to 20/ Section II. LABORATORY TEST: Must be within last 3 months of beginning program. (Attach copy of lab results) TEST FINDINGS DATE Drug Screening / 10 Panel List plus Ethanol negative results Ethanol Amphetamines, Barbiturates, Benzodiazepines, Cocaine Metabolites, Marijuana Metabolites, Methadone, Methaqualone, Opiates, Phencyclidine, Propoxyphene Page 1 of 8

2 Section III. IMMUNIZATIONS/SCREENINGS: (Attach copies of immunization) TB 2-step TB required unless documented negative PPD in the last year is presented OR Chest x-ray If new positive PPD or no documentation of prior positive and clear check x-ray provided. Repeat CXR is not required if documentation is provided and no symptoms of active disease per heath care provider Influenza vaccine TYPE/RESULTS Read Date: 1 st Skin Test (PPD Only) - Results: #1 2 step required before program begins 2 nd Skin Test (PPD Only) Results: #2 (at least 7 days from #1 read; not more than 21 days) Chest X-ray: (every 3 years) Results: Copy of radiology report required. Required: current season s vaccination. First session of the fall semesters will need to wait until the end of August or when the influenza vaccination becomes available. DATE Inj Date: #1 #2 Date: List any pertinent medication(s) the student is currently taking: This student does not have any health condition that would create a hazard to themselves or others. Agree Disagree If disagree, please explain This student does not have any lifting or mobility restrictions. Agree Disagree If disagree, please explain In your opinion, is the health of the applicant such that he/ she can undertake this program? Yes No This individual has been advised of the finding of this examination and has been encouraged to consult with his/her personal physician if appropriate: Yes No ADDITIONAL COMMENTS: Print (MD, DO, PA, or NP) Name Date: Signature of (MD, DO, PA, or NP) Phone Number Address PLEASE RETURN THE COMPLETED FORM TO: CHAFFEY COLLEGE Nursing Assistant Program, HS Haven Avenue Rancho Cucamonga, CA Page 2 of 8

3 Health Sciences Office HS-145 MANDATORY: The following 11 items need to be tested separately and all 11 items have to come back Negative on the lab result. Chaffey College Nursing Assistant program requires the following drugs must be tested. Drug Screen: 10 Panel List plus Ethanol: URINE TEST Drug Class Initial Test Level Also Known As Amphetamines 1000 ng/ml Barbiturates Benzodiazepines Cocaine Metabolites Marijuana Metabolites 50 ng/ml THC/Cannabinoid Methadone Methaqualone Opiates Phencyclidine 25 ng/ml Propoxyphene Ethanol.02 g/dl Alcohol Print (MD, DO, PA or NP) Name Date: Signature of (MD, DO, PA, or NP) Phone Number Address Lab report must show a negative reading for all 10 drugs plus Ethanol separately drugs cannot be combined Page 3 of 8

4 Student Health Services Chino or Rancho MACC Building If you would like to have your student physical done at Chaffey SHS, the following information may be of assistance to you. 1. Physicals are done in 3-5 pre-arranged appointments depending on your immunization status. The first appointment includes laboratory work, hearing testing, vision testing, TB screening and immunizations as required. If a TB test is required, you will be required to return for reading hours after the test. If a second TB test is required, it must be within 7-21 days after the first TB reading. No appointment is needed for test reading, however specific hours are scheduled in the clinic for readings please verify return time with the staff. PLEASE REFER TO 2 STEP TUBERCULOSIS TESTING FOR PERSONS ENTERING HEALTH CARE PROFESSIONS FOR CLARIFICATION OF THIS TESTING PROCESS. 2. After all blood testing and TB status has been completed, you will have a scheduled appointment with the physician or nurse practitioner for completion of the physical. If further immunizations or testing is needed we will make every effort to finish your physical on that day. Please allow at least 1 hour for each of the above- mentioned visits. We ask that you arrive minutes prior to your appointment time in order to complete the necessary paperwork for your physical. The approximate cost: Hearing/vision free, TB skin test PPD $10 each x 2 = $20. Drug screening $30. Current season s flu vaccine cost to be determined. If you have questions, please call us at (909) We wish you every success in your chosen career! Student Health Services Staff Page 4 of 8

5 2 STEP TUBERCULOSIS TESTING FOR PERSONS ENTERING HEALTH CARE PROFESSIONS In some people who are infected with TB, delayed-type hypersensitivity to tuberculin may wane over the years and therefore may test negative with the PPD testing. This initial test may simulate (boost) their ability to react to tuberculin causing a positive reaction to subsequent tests and can be misinterpreted as a new infection. Boosted reactions can also occur in persons who have had prior BCG vaccination. Two step testing is used to reduce the likelihood that a boosted reaction will be misinterpreted as a recent infection. Because of the potential for continued exposure to TB infected persons, all students applying to health professional programs will be tested using the 2-step testing procedure unless the student can provide documentation of a negative PPD test result within the last year. Following a negative TB skin test the person is retested in 1-3 weeks. If the second test is negative, the person is uninfected or anergic; if positive, a boosted reaction is likely. Please note that previous vaccination with BCG is not a contraindication to tuberculin skin testing. In order to complete the testing, the following visits will be required at the student health center: 1. TB test administration #1 2. TB reading 2-3 days after administration 3. TB test administration #2 (at least one week after and no later than 3 weeks after test TB reading) 4. TB reading 2-3 days after administration of Test #2 Whenever possible we will schedule your immunizations and other testing around your testing, but please be flexible with your availability for appointments. References: Calif Dept of Public Health (CDPH/CTCA Joint guidelines) California Tuberculosis Controllers Association Joint Guidelines 3/12/02. Page 5 of 8

6 2 STEP TESTING: (FOR PERSONS ENTERING HEALTH CARE PROFESSIONS) In some people who are infected with TB, delayed-type hypersensitivity to tuberculin may wane over the years and therefore may test negative with the PPD testing. This initial test may stimulate (boost) their ability to react to tuberculin causing a positive reaction to subsequent tests and can be misinterpreted as a new infection. Boosted reactions can also occur in persons who have had prior BCG vaccination. Two step testing is used to reduce the likelihood that a boosted reaction will be misinterpreted as a recent infection. Because of the potential for continued exposure to TB infected persons, all students applying to health professional programs will be testing using the 2-step testing procedure unless the student can provide documentation of a negative PPD test result within the last year. Following a negative TB skin test the person is retested in 1-3 weeks. If the second test is negative, the person is uninfected or anergic; if positive, a boosted reaction is likely. Two step testing should be used for the initial tuberculin skin testing of individuals who will be tested repeatedly, such as health care workers. Anergy testing is not recommended for routine use to distinguish a true negative result from anergy. Definition of a positive TB skin test: Previous vaccination with BCG is not a contraindication to tuberculin skin testing. Because most persons who have received prior BCG vaccination are from high prevalence areas of the world, previous vaccination should be ignored when interpreting a tuberculin skin test. >5mm induration: A. Persons known or suspected to have HIV infection B. Recent contacts to an active cause of pulmonary or laryngeal TB C. Persons with an abnormal chest x-ray consistent with TB disease D. Immunosuppressed individuals from medical conditions or medications 10mm induration: All persons except as noted above. First time positive PPD (converters) should be referred to San Bernardin Public Health for further work up and possible treatment of latent TB. The patient may call (909) to arrange an appointment with the San Bernardino office or the Ontario office. A chest x-ray will be done ($30). Patient can request that a copy be faxed to SHS at (909) Meds given for up to 9 months based on income can be as high as $10 per month. Page 6 of 8

7 Clinic & Immunizations Referrals for Program Physicals SAC Health System SAC-Norton 1455 East Third Street San Bernardino, CA (909) Primary Care Appointments (909) Dental Appointments Monday thru Thursday, 7:00am to 4:30pm TD: $22.00 PPD: $12.00 Real Occupational Testing Services 4025 Guasti Rd., Suite #215 Ontario, CA (909) (909) FAX Hours Mon, Wed, Fri: 10:00am 6:00pm Tue, Thurs 10:00am 3:00pm Student Physical (includes vision & hearing) - $20.00 Please mention you are a Chaffey Student Drug Screening offered Quest Diagnostics Locations: Corona Diamond Bar Pomona Upland Pinnacle Medical Group Lemon Ave, Unit N Rancho Cucamonga (909) Appointments (877) Hours: 8:00am 5:00pm Adult physical (includes vision & hearing) - $ $ TB: $15.89 TD: $65.00 San Bernardino County Walk-In-Clinic 351 N. Mt. View, Room 107 San Bernardino, CA (800) Monday thru Friday 8:00am 5:00pm TB: $19.00 TD: $19.00 San Bernardino Walk-In-Clinic Victor Valley Public Health Center Bear Valley Rd Hesperia, CA Same cost as above Mission Health Medical Center 5524 Mission Blvd Riverside, CA (951) Page 7 of 8

8 Monday thru Friday 9:30am 6:00pm Saturday 9:00am 1:00pm TB: TD: $45.00 Page 8 of 8