D Youville College School of Nursing Physical Examination Form This form is an annual requirement for all nursing udents enrolled in the DYC SON program. Please submit ALL pages of the completed form to CaleBranch a keep a copy for your records. PAGES 1 AND ARE TO BE COMPLETED AND SIGNED BY THE STUDENT. PAGES 3, 4, 5 ARE TO BE COMPLETED AND SIGNED BY A HEALTH CARE PROFESSIONAL. Student Demographics a Health Hiory: SSN #:_ Date of Birth: Name: La Fir Middle Local Address: Street City State Zip Code ( ) Phone Number HEALTH INSURANCE COVERAGE NAME OF COMPANY: POLICY #: GROUP #: Please check those coitions for which you have a hiory: Anemia/Blood disorder Infectious Mononucleosis Back Pain Arthritis/Joint Problems Kidney/Urinary Problems Blood Producing Cough Ahma/Hayfever Fainting/Convulsions/Epilepsy Hepatitis Heart Disease/Murmur Skin Rashes/Sores Diarrhea Tuberculosis Draining Wous/Infection Jauice High Blood Pressure Hernia Change in Bowel Habits Diabetes Ulcer/Garoenteritis Blood in your ools Allergies to Foods or Drugs Emotional Problems Cough DYC SON Physical Examination Form Page 1 of 5
Student Demographics a Health Hiory (cont.): NAME: DATE OF BIRTH: 1. Are you currently uer the care of a physician? If Yes, please explain. Are you currently on any medication? If Yes, please explain 3. Do you have any problems with your vision? If Yes, please explain 4. Do you have any allergies to food, drugs, pollens, latex, etc.? If Yes, please explain 5. How many colds have you had in the pa year? How long do they normally la? _ 6. Do you smoke? What? How many per day? 7. In the pa year has there been any change in your: a. Weight? How much? b. Blood Pressure? How much? Student Information Release a atteation: I am aware a uera that in order to maintain the health a safety of their clients a meet designated health laws, agencies used for clinical experiences may require selected information from my health record. I authorize release of pages 3 a 4 of this form to said agencies a to the program office. I also concur that the information above, atteed to by my physician, is true. _ Signature of Student Date DYC SON Physical Examination Form Page of 5
The following sections of this form MUST be complete by a Health Care Professional PATIENT NAME: DOB:_ HEIGHT: WEIGHT: BP: PULSE: Vision without corrective lenses: R: _ L: Vision with corrective lenses: R: _ L: CHECK EACH ITEM IN PROPER COLUMN. ENTER NE IF NOT EVALUATED. 1. Head, Neck, Face, Scalp, Skin. Ears, Nose & Throat 3. Oral Cavity 4. Lungs, Che 5. Heart 6. Abdomen, Viscera 7. Musculoskeletal 8. Hearing Normal Abnormal Comments: Limitations, if any: ALLIED HEALTH DEPARTMENTS LIST OF REQUIRED IMMUNIZATIONS 1. Tuberculosis screening - PPD or quantiferon Gold blood te required NOTE: In keeping with current Centers for Disease Control recommeations a -Step TB skin te (two TB skin tes adminiered 1-3 weeks apart) is required if this is fir PPD or if previous PPD was more than 1 months ago. If udent has previous PPDs documentation of TWO negative consecutive annual 1-Step TB skin tes within the la 13 months is required. If pa positive PPD result, a clear che x-ray (lab report required) is required. 1 PPD Date Placed: Date Read (mu be within 48 7 hours of placement): Comments: PPD Date Placed: Date Read (mu be within 48 7 hours of placement): Comments: OR (If PPD is positive, CXR mu be obtained a copy of the report mu be uploaded to Certified Profile showing a clear CXR result, no evidence of TB) Che X-Ray (if positive PPD only) Date: Results: OR quantiferon Gold blood te (lab report required): Date of te: Comments: DYC SON Physical Examination Form Page 3 of 5
Immunizations Cont. Patient Name: DOB: _. Rubella (Measles) Live Vaccine Please Note: For Mumps/Measles/Rubella Vaccines, mu have documentation of either having received iividual vaccines OR MMR vaccination previously. If prior vaccination documentation is not available, then documentation of immune serology for each component of the MMR vaccine is required on official lab report with reference ranges. 1 Dose Date: Dose Date: (Two doses of measles vaccination required, with fir dose given on or after fir birthday, a seco dose separated by at lea 8 days OR immune serology with lab report uploaded to Certified profile) Rubella Titer (if needed): Date: Result: 3. Mumps Vaccine 1 Dose Date: Dose Date: (Two doses of mumps vaccination required, with fir dose given on or after fir birthday, a seco dose separated by at lea 8 days OR immune serology with lab report uploaded to Certified profile) Mumps Titer (if needed): Date: Result: 4. Rubella Live Vaccine 1 Dose Date: Dose Date: (Two doses of rubella vaccination required, with fir dose given on or after fir birthday, a seco dose separated by at lea 8 days OR immune serology with lab report uploaded to Certified profile) Rubella Titer (if needed): Date: Result: 5. Tetanus/diphtheria/acellular pertussis [Tdap] (within 10 years) Date: (In keeping with current Centers for Disease Control recommeations, health care personnel younger than age 65 with direct patient contact who have not previously received a dose of Tdap, should receive a single dose of Tdap to replace one Td booer dose. Waiting at lea years since la Td booer is suggeed.) 6. Hepatitis B Series: rd 1 Dose Date: Dose Date: 3 Dose Date: Hepatitis B Titer (if needed): Date:_ Result:_ 7. Varicella Zoer Vaccine: 1 Dose Date: Dose Date: Hiory of Chicken Pox (date required): Varicella Titer (if needed): Date: Result: (All persons age 13 years a older without evidence of immunity to varicella, or documented hiory of having chickenpox are required to have two doses of varicella vaccine, separated by at lea 4 weeks.) DYC SON Physical Examination Form Page 4 of 5
Immunizations Cont. Patient Name: DOB: _ 8. Influenza Vaccine (annual requirement) Date: (In keeping with current Centers for Disease Control recommeations, it is recommeed that all health care personnel without known contraiications should receive an annual influenza vaccine. If iividual cannot receive the vaccine for any medically iicated or personal reason, they may sign the flu declination waiver fou on CaleBranch in place of a vaccine a will be required to wear a mask in all clinical facilities as outlined by their policy during flu season.) Healthcare Provider Signature Date _ Print Name or Stamp here ( )_ Address Phone Number DYC SON Physical Examination Form Page 5 of 5