Instructions: Please bring these forms to your Physical Examination & TB Test and have the Doctor fill them out. (Where applicable)
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1 Instructions: Please bring these forms to your Physical Examination & TB Test and have the Doctor fill them out. (Where applicable) 1. The physician s examination certification form. Ask your doctor to sign this form certifying you that you can perform a CNA work. 2. The Mantoux PPD Test or TB test. If you go to your doctor, ask them that you want a TB test. 3. Tuberculosis Assessment and History and Physical forms are for you to complete. Please submit these documents at your earliest convenience or on the 1 st day of class.
2 History and Physical Name: Age Sex Address: Telephone Number: Family Physician: Date of Last Visit Reason: Family History: Nervous Mental illness Diabetes TB Have you had any of the following? DISEASE OF Yes No DISEASE OF Yes No DISEASE OF Yes No Brain Genitals Nephritis Eyes Dizziness Rheumatism Ears Frequent Colds Vomiting Blood Nose Fainting Episodes Diabetes Throat Deafness Backaches Heart Jaundice Injuries Lungs Chest Pain Operations Liver Intestines Constipation Spleen Gallbladder Bloody BM Bones Joints Painful Urination Skin Bladder Blood in Urine Back Chronic Sinus Prob. Shortness of Breath Couching Blood Convulsions Asthma Kidneys Kidney Stones Hay Fever Poor Appetite High Blood Pressure Frequent Sore Throat Indigestion Nervous Breakdown Lymph Nodes Bronchitis Malaria Chronic Cough Palpitations Rheumatic Fever Recurrent Nausea Pneumonia Paralysis Swollen Ankles Freq. Headaches Cancer/Tumors Stomach Ulcers Arthritis Other serious illness (list) Do you hear well? Have you been rejected or discharged from the military because of illness or injury? Have you received any pension, insurance payments or compensation for an injury or illness? Do you have any defect, deformity or disease, which may interfere with your work? State the details of illness, injuries, operations or defects I certify that the above answers are true, and give the examining physician permission to submit a report to SacMed Training, LLC. Student Signature: Date:
3 Physical Examination Student Name Date: Height Weight B/P Pulse General Appearance H.E.E.N.T Chest Heart: Rhythm Murmurs Abdomen: Organomegally Masses Extremities: Comments: I have examined this student and have found no condition that appears to prevent him/her from performing the duties and responsibilities of being a nursing assistant. Further, I have found this person to be sufficiently free of disease that would create a hazard to himself/herself, fellow students, or to the residents/patients or visitors of the clinical site. M.D. Signature Date
4 MANTOUX PPD SKIN TESTING Name: Date Please answer the following questions: Have you had Tuberculosis? Has anyone close to you had Tuberculosis? Have you ever been exposed to Tuberculosis? Have you ever had a reaction to the TB test? Explain Have you had stomach or intestinal surgery? Were you born in the Continental United States? Have you ever had BCG vaccination for TB? How long ago? # years Are you presently in good health? Is your immune system working well? Are you taking steroid or cortisone? Are you receiving radiation or chemotherapy? I understand that this test is required as a condition of being accepted in the NA program and potential side effects which are possible as with any medication have been explained to me. I am currently not pregnant or nursing a baby and I am in good health. I authorize the administration of the Mantoux PPD skin test at this facility and I understand that I must report back for the test site to be examined at the appointed time. Student Signature Date Test: Date Lot # Right Arm [ ] Left arm [ ] Given by: Date Read Results: [ ] Negative [ ] Positive Induration (mm) Read by
5 TUBERCULOSIS ASSESSMENT (For use with students who are PPD positive) Please complete the following brief questionnaires about your health. Do you currently have any of the following symptoms? Yes No 1. Cough lasting greater than 2 weeks? 2. Unexplained weight loss? 3. Loss of appetite? 4. Unexplained fever? 5. Night sweats? 6. Blood tinged sputum production? 7. Have you ever received BCG vaccine? 8. What is your country of origin? 9. Have you lived in any other country within the past 10 years? 10. Have you been treated for TB? If yes to any question, please describe symptoms further. When did this start? Have you sought treatment? If yes, what treatment was done? Student Signature Date FOR OFFICE USE ONLY Was this student referred for further evaluation? Yes No If yes, to whom? Yes No Chest X- Ray? Yes No Medications? Yes No Work Restrictions? Yes No If yes, describe: Date
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