Gaston College Health Education Division Student Medical Form

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1 Student Name: Date: Gaston College Health Education Division Student Medical Form Associate Degree Nursing Cosmetology Dietetic Programs Health and Fitness Science Medical Assisting Nursing Assistant Phlebotomy Practical Nursing Therapeutic Massage Veterinary Medical Technology 1

2 REPORT OF MEDICAL HISTORY to be completed by student LAST NAME (print) FIRST NAME MI STUDENT ID NUMBER PERMANENT ADDRESS CITY STATE ZIP CODE PHONE NUMBER GENDER DATE OF BIRTH MARITAL STATUS M F S M OTHER SEMESTER ENTERING (circle): FALL SPRING SUMMER YEAR 20 PREVIOUSLY ENROLLED IN THIS PROGRAM? YES NO IF YES, DATES: The following health history is confidential, does not affect your admission status and, except for in an emergency situation or by court order, will not be released without your written permission. Please attach additional sheets for any items that require fuller explanation. PERSONAL HEALTH HISTORY to be completed by student Have you ever had or have you now: (please check at the right of each item and if yes, indicate year of first occurrence) Yes No Year Yes No Year Yes No Year High blood pressure Diabetes Psychiatric illness Stroke Glaucoma Suicide Blood or clotting disorder Cancer (type): Alcohol/drug problems Heart attack before age 55 Cholesterol or blood fat disorder Asthma Frequent or severe headache Dizziness or fainting spells Knee problems Neck injury Back injury Hearing loss Recurrent back pain HEIGHT WEIGHT Please list any drugs, medicines, birth control pills, vitamins, minerals, and any herbal/natural (prescription and non-prescription) you use and how often you use them. Are you being treated for a chronic illness (psychological or physical)? Yes* No *Explain, if yes Do you have any allergies (food, insects, materials, medication, etc.)? Yes* No *Explain, if yes 2

3 IMMUNIZATION RECORD To be completed by Physician/Physician Assistant/Nurse Practitioner of Clinic. A complete immunization record from a physician or clinic may be attached to this form. Last Name First Name MI DOB Step 1 Date Read: 2-Step Tuberculin (PPD) Test Step 1 Results: Step 2 Date Step 2 Results: Read: Chest X-Ray (if positive): MMR & Booster or Positive Titer (Disease date not accepted) #1 #2 Titer Date: Titer Results Measles Mumps Rubella Tetanus/Pertussis (Td) or Tdap Flu Shot Date (within 10 years): Hep B Hep A/B Date: Hepatitis B or A/B Vaccine Declination in file #1 #2 #3 Titer Date: Titer Results: Varicella (Chicken Pox) or Positive Titer (Disease date not accepted) #1 #2 Titer Date: Titer Results: X Signature of Physician/Physician Assistant/Nurse Practitioner Date Print Name of Physician/Physician Assistant/Nurse Practitioner Office Address Phone Number City State Zip Code 3

4 PHYSICAL EXAMINAION To be completed and signed by Physician/Physician Assistant/Nurse Practitioner or clinic Last Name First Name MI Date of Birth Permanent Address City State Phone Number Height Weight TPR / / BP / Are there abnormalities? Normal Abnormal DESCRIPTION (attach additional sheets if necessary) 1. Head, Ears, Nose, Throat 2. Eyes 3. Respiratory 4. Cardiovascular 5. Gastrointestinal 6. Hernia 7. Genitourinary 8. Musculoskeletal 9. Metabolic/Endocrine 10. Neuropsychiatric 11. Skin 12. Mammary A. Is there loss or seriously impaired function of any paired organs? Yes No Explain: B. Is student under treatment for any medical or emotional condition? Yes No Explain: C. Recommendation for physical activity (physical education, intramurals, etc.) Unlimited Limited Explain: D. Is student physically and emotionally healthy? Yes No Explain: E. Does student have a latex allergy Yes No Explain: Yes No Based on my assessment of this applicant s physical and emotional health, he/she demonstrates evidence that is indicative of his/her ability to provide safe healthcare to the public. X Signature of Physician/Physician Assistant/Nurse Practitioner Date Print Name of Physician/Physician Assistant/Nurse Practitioner Office Address Phone Number City State Zip Code 4

5 Gaston College Nursing Assistant Program Health Assessment This is to verify that has been (Name of Student) Evaluated for the following altered state of health: (Identify Condition) After thorough examination of this individual, his/her physical limitations related to the practice of nursing assistant, if any, have been noted below. Physical Limitations Able to move from room to room and maneuver in small spaces, stand and walk for extensive periods of time Able to participate in practice of first aid procedures and practice of administering cardiopulmonary resuscitation on mannequins Able to assist patients moving in bed Able to position adult patients in bed Able to transfer patients from bed to chair Able to lift pounds several times daily Able to be assigned to any medical specialty area in hospitals or long-term care during clinical practice Able to receive required program immunizations (MMR, Hepatitis B series, Varicella, Tetanus Booster, TB skin test) Other (Explain): Check here if able to perform Check here if unable to perform If unable to perform, please explain Signature stamp or Clinic Stamp REQUIRED: ( ) Signature of Attending Physician Date Phone Number Office Address City State Zip Code 5

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