Radford University School of Nursing GRADUATE HEALTH RECORD FORM
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1 Revised 6/2018 Radford University School of Nursing GRADUATE HEALTH RECORD FORM The School of Nursing requires a complete Health Record and Certificate of Immunization be completed and signed by a licensed health care provider. All areas must be completed, if they do not apply, mark N/A. Your offer of admission can be denied if the health record is such that you would not be successful in meeting the objectives of the School of Nursing. The School of Nursing requires you to do a complete health record before you start the nursing major. If the health record shows issues of concern the results will be shared with the clinical agencies that the School of Nursing uses for clinical. The clinical agencies will determine whether you can come to their agency for clinical. If the clinical agency refuses to allow you in clinical you will be dismissed by the School of Nursing. Fall Health Record due date is August 1 Spring Health Record due date is January 3 PERSONAL DATA: Name Last First Middle Social Security Number: Date of Birth: RU ID # Local Address Telephone Number: ( ) Permanent Address Telephone Number: ( ) Other contact information (cell phone, pager) Radford address: NEXT OF KIN: Name Next of Kin Relationship Address Telephone ( ) In Case of Emergency Notify: Name Relationship Phone (work) ( ) Phone (home) ( ) Cell ( ) 1
2 HEALTH CARE: Name and Credentials (MD, NP, etc.) of primary provider Address Telephone ( ) Health Insurance Company Policy No Health Insurance Company Member Services Telephone Number ( ) HEALTH HISTORY INFORMATION: Answer each question. If it does not apply mark N/A. 1. Name any illness or health condition for which you are CURRENTLY under treatment: 2. If you have been hospitalized state: Date Name and Address of Hospital Name of Physician Diagnosis Date Name and Address of Hospital Name of Physician Diagnosis Date Name and Address of Hospital Name of Physician Diagnosis 3. List any medicine, food or environmental substance to which you are ALLERGIC: 4. List any medications you are now taking, include drug name, dose and reason for taking the drug 2
3 5. Check boxes to indicate whether you have (or had in past) these problems. Provide details of positive answers on a separate sheet and attach with the health record. We may request that you have your health care provider send further information after we review your answers. YES NO DATE CONDITION ADD/ADHD Anemia (including sickle cell anemia) Asthma Bleeding disorder Blindness (complete or partial) Cancer (including leukemia, Hodgkin Disease) Colitis, ulcerative Cystic Fibrosis Diabetes Epilepsy or other seizure disorder Glaucoma Hearing loss (complete or partial) Heart enlarged Heart murmur Heart valve problem Hepatitis High blood pressure Hypoglycemia Inflammatory bowel disease Migraine headache Pneumonia Rheumatic Fever Rheumatoid arthritis Stomach ulcers Substance abuse (alcohol and/or drugs) Thyroid trouble Tuberculosis Emotional/Psychiatric problems Other (describe below) Other: Please describe 3
4 TUBERCULOSIS SCREENING (required): (TINE Test is NOT acceptable) Two-Step Tuberculosis Skin Test (TST) or Quanteferon Gold (QFT-G): The CDC (2005) and Occupational Health and Safety Administration (OSHA, 1994) require that a two-step baseline TST or Quanteferon Gold (QFT-G be performed on students/health care workers. Two-step testing consists of an initial TST and, if that result is negative, a second TST is administered 1-3 weeks after the first. To be valid, each TST reaction must be read within hours following administration. The test must be read by a RN, MD, or qualified health professional. If, during the past 12 months, a TST was administered and read within hours, it will be accepted as the first-step of the two-step process if proper documentation can be provided. Students have the option to do the Quanteferon Gold (QFT-G) which is a serology test. Tuberculosis Skin Test (TST) 2 Step Results: 1 st Step: LF RF Date: Given by: Read by: Date: TB Skin Test was Negative/Positive (circle one) If positive: Measurement of induration 2 nd Step: LF RF Date: Given by: _ Read by: Date: TB Skin Test was Negative/Positive (circle one) If positive: Measurement of induration OR Quanteferon Gold (QFT-G): Negative/Positive (circle one) Signature DATE Students with a previous Positive PPD skin test should not have a TST repeated. The student may choose to obtain a QFT to verify the positive PPD or obtain a Chest x-ray. Documentation of positive PPD is required and a copy of the either the NEGATIVE QFT result or a copy of the radiologist report of the chest x-ray must be submitted with this health form. Students testing positive with the 2 step TB skin test or Quanteferon Gold (QFT-G) need to take INH medication as prophylaxis. If currently on INH or if INH treatment has been completed, please provide documentation. If chest x-ray is negative, a repeat chest x-ray is not required unless symptoms develop that could be attributed to tuberculosis. EXAMINER S SIGNATURE DATE 4
5 CERTIFICATE OF IMMUNIZATION: The immunizations listed below are in accordance with recommendations from the: Advisory Committee on Immunization Practices, American Academy of Pediatrics, and American Academy of Family Physicians (2003). Please access the following source for further information on vaccines: CDC National Immunization Program web site IMMUNIZATIONS TETANUS, DIPTHERIA, and ACELLULAR PERTUSSIS(Tdap) VACCINATION Tdap replaces a single dose of Td for adults aged years who have not received a dose of Tdap previously. All students are required to produce documentation of adult Tdap vaccination before entrance into Radford University School of Nursing MENINGOCOCCAL CONJUGATE VACCINE (2) Meningococcal Booster is required after the age of 16 HEPATITIS B VACCINE MEASLES, MUMPS, RUBELLA (MMR) If born before 1957, only one dose is required. If born during or after 1957, both doses are required. VARICELLA ZOSTER You either get Two (2) doses for persons who are susceptible. OR The Serological Confirmation of Immunity Cannot State Had Disease ORAL POLIO VIRUS (OPV) VACCINE Licensed Health Provider Signature Licensed Health Care Provider Printed Name Address / / Mo VACCINE 2) / / Mo VACCINE 2) / / Mo 1) / / Mo VACCINE DOSES ADMINISTERED Tdap replaces a single dose of Td for adults aged years who have not received a dose of Tdap previously. All students are required to produce documentation of adult Tdap vaccination before entrance into Radford University School of Nursing 2) / / Mo 2) / / Mo 3) / / Mo Have 2 Vaccines: (1) OR have Serological Confirmation of Measles Immunity / / Mo OR (2) AND Serological Confirmation of Rubella Immunity / / Mo Serological Confirmation of Immunity (Must attach a copy of the Lab Report) 2) / / Mo / / Mo 3) / / Mo 4) / / Mo Day Year Date Phone Number ( ) *MEDICAL EXEMPTION: DPT Td Tdap Polio MMR Hepatitis B Series Varicella zoster As specified in Article C. (II) of the Code of Virginia, I certify that administration of the vaccine(s) designated above would be detrimental to this student s health. The vaccine(s) is (are) specifically contraindicated because This contraindication is permanent (or) temporary and expected to preclude immunization until This contraindication is permanent (or) temporary and expected to preclude immunization until Physician or Health Department Official Signature Date: Phone: 5
6 PHYSICAL EXAMINATION (to be completed by primary provider): Height Weight Blood Pressure Pulse Respiratory Temperature 1. Please indicate any abnormalities in the following and describe findings at right: YES NO YES NO Skin Heart Endocrine Lungs Lymph Abdomen Eyes/Vision Genitals Ears/Hearing Neurological Noses/Smell Mental Health Mouth/Throat Emotional Stability Neck/Thyroid Breasts Other 2. Do you recommend any limitations to physical activities? Yes No If yes, specify in detail 3. In your professional opinion, do you think this student has an adequate state of physical and mental health to function in a clinical nursing program? Yes No If no, specify your concern(s) 4. General Comments: Attention Examiner: Your signature below indicates that you have reviewed this entire document Examiner s Signature Date Examiner s Printed Name Address Telephone Number ( ) Student Signature Date 6
Student Health Record
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Name Age Birthday / / Sex Last First MI. Home Address Street Apt City State Zip Code Home phone: ( ) Cell phone: ( ) Name of parent(s) or guardian:
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Student Health Record
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