HEALTH SERVICES DEPARTMENT HEALTH HISTORY & PHYSICAL EXAM FORM HEALTH INFORMATION TECHNOLOGY

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1 HEALTH SERVICES DEPARTMENT HEALTH HISTORY & PHYSICAL EXAM FORM HEALTH INFORMATION TECHNOLOGY Purpose: Completion of this packet is requested as part of the admissions process. The information you provide will be evaluated against the essential/technical standards that have been validated as essential for participation in the particular program for which you have applied. Instructions: Please complete Section 1 and 2 of this packet. Be sure you sign and date the forms where it s requested. Your name and M # number must be on ALL pages. All entries made by you need to be in ink. Your physician or health care provider needs to complete the Physician/Health Care Provider Section 3 and 4 when you have your physical examination. All of these forms must be completed and in compliance with requirements before review by Health Services Department nursing staff. Any packets that are not complete will not be accepted. It will take hours for Health Services Department nursing staff to review completed packets for clearance, so please plan accordingly. Monroe Community College is a unit of the State University of New York. It is the policy of the University and College not to discriminate on the basis of age, sex, race, religion, national origin, color, disability or marital status in admission, employment, and treatment of students and employees in any educational activity administered by any of its units.

2 SECTION 1 STUDENT COMPLETE THIS SECTION Name: of Birth: Address: Student M# M00 SS#(last 4 digits) Insurance Carrier: Insurance ID number: Tel. Number: ( ) Cell Number: ( ) Primary Care Physician Tel. Number: ( ) Emergency Contact: Tel. Number: ( ) Cell Number: ( ) **CPR EXPIRATION DATE: HEALTH HISTORY **ORGANIZATION: ****CPR Card must be turned in to the Nursing Dept. directly**** ALLERGIES: Latex Bees Medicine (please list) Food (please list) Other Prescription/over-the-counter medications taken: Do you smoke or chew tobacco? (Please circle which one if you do) If yes, would like info on quitting? YES or NO Please put an X in the columns below if applicable: (please circle condition, indicate when & explain on lines below) ADD/ADHD Alcohol use, abuse or addiction Now Past Now Past Now Past Now Past Concussions, Head injury Hepatitis A, B or C Seizures or epilepsy -petit mal, or Traumatic Brain Injury grand mal, partial Last seizure? Chronic Fatigue Syndrome Hernia Severe menstrual cramps or Fibromyalgia Anemia Deaf or Hard of Hearing High Blood Pressure (Hypertension) Anxiety and/or Depression Hospitalization panic attacks (please mark now if within past 2 months) Arthritis Asthma, Emphysema, or Chronic Bronchitis Diabetes Type 1 Type 2 Drug use, abuse or addiction Irritable Bowel Syndrome Kidney stones or other disorder Sexually transmitted Infections Sickle Cell Disease Skin Problems Back problems Eating disorder Low Blood Pressure (Hypotension) Surgery (please mark now if within past two months) Bladder or kidney Eye/Vision problems Mental Health Concern Thyroid Disease Disease Bleeding Tendency Gall Bladder Disease Migraines Tuberculosis Bone problem GERD, Hiatal Hernia or Stomach Ulcer Neurological issue (MS, MD, Spina Bifida, or CP) Stroke Vertigo (dizziness), or history of fainting Cancer Heart Disease Organ Transplant Witnessed or experienced violence or abuse. Colitis or Celiac Disease Heart rhythm problems or weak heart muscle Post-Traumatic Stress Disorder (PTSD) Other : I attest to the truthfulness of the above statements and that I am free from habituation or addiction to depressants, stimulants, narcotics and other behavior altering substances. Page 1

3 SECTION 2- STUDENT & PROVIDER COMPLETE THIS SECTION TUBERCULOSIS SCREENING: Do you currently have or have you had in the past year any of the following: Easily fatigued? Chills or Night Sweats? Loss of Appetite? Unexplained Weight Loss? Swelling in the neck, armpits, groin Cough with sputum 3 weeks? Blood Tinged Sputum? Yes No If yes, please explain: TB test or PPD (purified protein derivative), is a skin test to see if you have ever been exposed to Tuberculosis. Have you had a TB test before? If yes, was your TB test Positive? Were you born in the USA? If not, where were you born? How long have you lived in the U.S.? Have you ever been told that your immune system is compromised? Have you ever been referred to your own MD/Health Clinic after having a positive TB test? Have you ever taken a medication for Tuberculosis? Did you complete the course of medication for treatment of Tuberculosis? Yes No Comments STUDENT S SIGNATURE: DATE: PROVIDER SIGNATURE: DATE REVIEWED: PLAN: Page 2

4 SECTION 3 TO BE COMPLETED BY PHYSICIAN OR HEALTH CARE PROVIDER IMMUNIZATIONS REQUIRED FOR ALL MEDICAL PROGRAMS FOR CLINICAL PARTICIPATION MMR (MUMPS, MEASLES, RUBELLA): VACCINE #1 VACCINE #2 OR POSITIVE MMR BLOOD TITER: MEASLES MUMPS RUBELLA VARICELLA VACCINE (Chicken Pox): OR POSITIVE VARICELLA TITER: VACCINE #1: VACCINE #2: VARICELLA OR DATE OF VARICELLA DISEASE: DISEASE: TD or TDAP (please circle one): Administered within 10 years INFLUENZA VACCINE VACCINE #1 VACCINE #1 MENINGITIS VACCINE: VACCINE #1 VACCINE #2 Administered within 10 years OR: I have received the information regarding meningitis and decline to receive the vaccine at this time. I understand that by declining I could be at risk of contracting meningitis. HEPATITIS B INFORMATION: I understand that due to my occupational exposures to blood I may be at risk of acquiring Hepatitis B virus Infection. I did receive the Hepatitis B immunizations. Please enter dates of each dose below. If you are in the middle of receiving the series please check the box to decline and sign and date where appropriate. Continue to send in the dates as they are received. Dose #1 OR Decline the vaccine at this time; I understand that by declining I continue to Dose #2 Dose #3 be at risk of acquiring Hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood and wish to be vaccinated, I can receive the vaccines from my physician or the health care agency that employs me. PPD SKIN TEST Given: Read: Result: ***Required annually*** POS NEG ***Positive PPD, chest X-ray results: : Result (circle one): Normal Abnormal Healthcare Provider Signature/Stamp Page 3

5 ALLERGIES MEDICATION & SUPPLEMENTS (LIST ALL) NONE Height: Weight: Blood Pressure: / Pulse: Uncorrected Vision: R / L / Corrected Vision: R / L / AREA EXAMINED NORMAL ABNORMAL DESCRIBE ABNORMAL FINDINGS HAND/SKIN HEAD/EYES EARS/NOSE/THROAT/MOUTH NECK/NODES CHEST/LUNGS CARDIOVASCULAR Carotid Arteries Neck Veins Apical Pulse Heart Murmurs Heart Size ABDOMEN MUSCULOSKELETAL/EXTREMITY MUSCULOSKELETAL/SPINE NERVOUS SYSTEM GENITOURINARY SECTION 4 PHYSICIAN OR HEALTH CARE PROVIDER, carefully read the following statement, and check the appropriate boxes. 1. Are there musculoskeletal restrictions related to mobility, range of motion, lifting, or manual dexterity? Yes No If yes, please explain: 2. Are there uncorrected hearing restrictions which would impair the student from hearing audible alarms or engaging in telephone or oral communication with patients? Yes No If yes, please explain: 3. Are there uncorrected sight restrictions which would impair the student from accurately reading gauges and calibrated equipment? Yes No If yes, please explain: I performed the above medical evaluation and found to the best of my knowledge, him/her to be free from physical or mental impairments, including habituation or addiction to depressants, stimulants, narcotics, alcohol or other behavior-altering substances which might interfere with the performance of his/her duties or would pose a potential risk to patients or personnel. YES NO If NO is checked, please identify those problems which might interfere with the performance of his/her duties or would pose a potential risk to patients or personnel. PHYSICIAN S/HEALTH CARE PROVIDER (WITH TITLE) SIGNATURE PRINT PHYSICIAN S/HEALTH CARE PROVIDER LAST NAME/STAMP PHYSICIAN S ADDRESS DATE OF EXAM (Must be within one year of entering program) PHYSICIAN S TELEPHONE NUMBER OFFICE FAX # (IF APPLICABLE) RETURN TO: MONROE COMMUNITY COLLEGE 1000 EAST HENRIETTA RD. PHONE: , FAX HEALTH SERVICES DEPARTMENT ROCHESTER, NY Page 4

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