HEALTH SERVICES DEPARTMENT HEALTH HISTORY & PHYSICAL EXAM FORM NURSING PROGRAM

Transcription

1 STUDENT ID HEALTH SERVICES DEPARTMENT HEALTH HISTORY & PHYSICAL EXAM FORM NURSING PROGRAM 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 all of Part 1 of this packet. Be sure you sign and date the forms where it s requested. Your name and ID 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 Part 2, the Physician/Health Care Provider Section, 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, 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 STUDENT ID MEDICAL CAREER PROGRAM HEALTH HISTORY & PHYSICAL EXAM CHECKLIST The checklist below must be completed by each student in a medical career program at Monroe Community College. This form must be included with the Health History & Physical Exam booklet. If there are any items not completed, the booklet will NOT be accepted or processed for clearance. It is very important to double check and make sure your booklet is complete. Student Name: Medical Program: Checklist: Part I: Section 1 Student personal information (p. 1) Section 2 Student personal health history (pp. 1-2) (including signature and date) Section 3 Student family history (p. 3) Section 4 Student personal history, cont. (p. 3) Section 5 Medical Records Release Authorization Student signature required (p. 4) Section 6 Student signatures for truthfulness (p. 4) Section 7 Student Technical Standards Checklist (p. 5) Section 8 Tuberculosis Screening (p. 6) Part II: Section 1 Meningitis & Hepatitis B Declination - Student signature & date required (p. 7) Section 2 Immunizations & Complete physical given by physician, including: Height, Weight, Blood pressure & Vision (pp. 7-9) Section 3 Three questions related to physical - completed by Physician (p. 10) Section 3 Clearance with/without restrictions including of physical exam, signature and address of physician or healthcare provider (p. 10) Student ID: _ Semester: I have read and completed all of the items listed above and my Health History & Physical Exam is complete. Student Signature

3 STUDENT ID ****PART 1 Student complete section 1 through 7 and sign where requested**** SECTION 1 STUDENT COMPLETE THIS SECTION Name: of Birth: Address: Student ID# SS# Insurance Carrier: Tel. Number: ( ) Cell Number: ( ) Primary Care Physician Tel. Number: ( ) **CPR EXPIRATION DATE: **ORGANIZATION: ****CPR Card must be turned in to the Nursing Dept. directly**** SECTION 2 STUDENT COMPLETE THIS SECTION IF THE ITEM LISTED BELOW HAS BEEN A PROBLEM IN THE PAST, OR IS CURRENTLY A PROBLEM, WRITE YES AND EXPLAIN. YES EXPLANATION ALCOHOLISM ARTHRITIS ANEMIA SICKLE CELL DISEASE ASTHMA SHORTNESS OF BREATH WHEEZING CHRONIC COUGH SWOLLEN GLANDS CHRONIC SORE THROAT FREQUENT HOARSENESS TUBERCULOSIS EMPHYSEMA BLEEDING TENDENCY CANCER UNUSUAL BLEEDING CIRRHOSIS HEPATITIS JAUNDICE KIDNEY PROBLEMS/DISEASE WEAK URINARY STREAM PAINFUL URINATION CLOUDY OR BLOODY URINE ULCER (STOMACH OR DUODENAL) VOMITING BLOOD COLITIS CHANGE IN BOWEL HABITS DIARRHEA BLACK OR BLOODY STOOLS CONSTIPATION DIFFICULTY SWALLOWING MENTAL ILLNESS DEPRESSION (MODERATE) UNUSUAL FEELING OF TENSION, ANXIETY, UNHAPPINESS DIFFICULTY SLEEPING EXTREME FATIGUE DIABETES MELLITUS HERNIA Page 1

4 STUDENT ID SECTION 2 (Cont.) STUDENT COMPLETE THIS SECTION IF THE ITEM LISTED BELOW HAS BEEN A PROBLEM IN THE PAST, OR IS CURRENTLY A PROBLEM, WRITE YES AND EXPLAIN. YES EXPLANATION HEART DISEASE HEART MURMUR HIGH BLOOD PRESSURE IRREGULAR HEART BEAT PALPITATIONS CHEST PAIN SWOLLEN ANKLES RHEUMATIC FEVER STROKE THYROID PROBLEM FEVER (PROLONGED) EXCESSIVE WEIGHT LOSS/GAIN LOSS OF APPETITE OR EXCESSIVE HUNGER NAUSEA VOMITING BACK PAIN JOINT OR MUSCLE PAIN HEADACHE (FREQUENT OR SEVERE) LOSS OF CONSCIOUSNESS/FAINTING LOSS OF HEARING EPILEPSY OR SEIZURES WEAKNESS OR PARALYSIS NUMBNESS OR TINGLING DIZZINESS EYE PAIN BLURRING/LOSS OF VISION EXCESSIVE SWEATING OR HOT FLASHES SKIN RASH, BURNING OR ITCHING SKIN INFECTIONS SKIN SORE THAT DOESN T HEAL MOLE THAT HAS CHANGED COLOR OR SIZE PAIN OR LUMP IN BREAST VAGINAL DISCHARGE PAIN OR SWELLING IN TESTICLES SORE OR DISCHARGE FROM PENIS DRUG ADDICTION 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. Student Signature Page 2

5 STUDENT ID SECTION 3 STUDENT COMPLETE THIS SECTION FAMILY HISTORY: Are your parents, siblings, children still alive? If not, fill in below. Family Member Father Mother Sister/Brother Children Check any health problems which your family members have had: Bleeding tendency. Heart Disease. Cancer. Mental Illness Stroke Kidney disease Tuberculosis (recent history) High blood pressure Diabetes SECTION 4 STUDENT COMPLETE THIS SECTION PERSONAL HISTORY (CONTINUED): Do you have any limitations of physical activities? NO YES IF YES, EXPLAIN: Do you have medication allergies or severe allergies to bee stings or other substances? NO YES IF YES, EXPLAIN: Do you take any medicines on a regular basis? If YES, list names of medicines, the doses and how often you take it. NO YES IF YES, EXPLAIN: Do you have any current problems (physical or emotional handicaps) that you would like Health Services to be aware of? NO YES IF YES, EXPLAIN: In the space below, please list all hospitalizations, surgeries, biopsies, fractures or other serious injury. Identify the problem and date if within the past five years. Page 3

6 STUDENT ID SECTION 5 STUDENT COMPLETE THIS SECTION Medical Records Release Authorization I hereby authorize Monroe Community College Health Services to furnish a copy of my medical history and physical examination form upon request by affiliating clinical agencies as required by New York State law. I understand that I have a right to receive a copy of this authorization upon request. This authorization shall become effective immediately and shall remain in effect until I complete my course of studies in the Program or until I am no longer employed as a faculty member in the Department. Signature SECTION 6 STUDENT COMPLETE THIS SECTION Student Checklist Included on next page Section 7 The Student Evaluation Checklist for your health Career Program is included on the next page. Please complete before signing below. *****Not required for Health Information Technology**** I attest to the truthfulness of responses to sections 1 through 7. _ STUDENT SIGNATURE DATE If you are under 18, this authorization must also be signed by a parent or guardian. _ PARENT OR GUARDIAN SIGNATURE DATE Page 4

7 STUDENT ID SECTION 7 - STUDENT COMPLETE THIS SECTION STUDENT CHECKLIST EVALUATION OF TECHNICAL STANDARDS FOR NURSING Essential Functions for Participation in the Nursing Program Yes No Yes No Yes No Stand Climb Grasp Sit Carry Twist Walk Hold/Support Feel Bend Push See Reach Pull Hear Lift>35# Detect Odors Speak Each Participant in the Nursing program must have the ability, unaided or with the assistance of reasonable accommodation, to perform these Essential Functions. Reasonable accommodation is a modification or adjustment that enables an otherwise qualified individual with a disability to have an opportunity to attain the same level of performance or to enjoy equal benefits and privileges that are available to a similarly situated individual without a disability. A reasonable accommodation is defined on a case-by-case basis and must take into consideration: 1. The specific abilities and functional limitations of the individual. 2. The specific functional requirements of the Nursing program. Reasonable accommodations are directed toward providing an equal educational and/or employment opportunity for the disabled individual while providing for the safety of the individual, client and agency staff. Each participant in the Nursing program, either unaided or with the assistance of reasonable accommodation, must be able to: Carry out standard nursing skills required by a Registered Nurse, such as, but not limited to, performing physical assessment, maintain sterile technique, performing cardiopulmonary resuscitation Manipulate equipment that requires both fine and gross motor skills such as, but not limited to, sphygmomanometer, infusion controller/pump, syringe, weight scale Communicate in an understandable matter. A. Verbally: person-to-person & over telecommunications devices and B. In writing: longhand, by electronic/computer devices Interpret written, verbal and electronic communication accurately Maintain an alert level of consciousness and orientation to time, place and person at all times Maintain a level of functioning unimpaired by substances such as alcohol, prescription or illegal drugs Yes No Not Known If you have answered no or not known, explain Student Signature Page 5

8 STUDENT ID SECTION 8 - STUDENT & PROVIDER COMPLETE THIS SECTION TUBERCULOSIS SCREENING: Do you currently have or have you had in the past year any of the following: Prolonged unexplained fever? Easily fatigued? Weakness? Chills or Night Sweats? Chest Pain? 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 6

9 STUDENT ID ***PART II TO BE COMPLETED BY STUDENT & PHYSICIAN OR HEALTH CARE PROVIDER*** SECTION 1 STUDENT MUST COMPLETE AND SIGN REQUIRED BY NEW YORK STATE: All students regardless of age: MENINGITIS VACCINE, I did receive the meningitis vaccine on 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. Student Signature MEDICAL PROGRAM REQUIRED: 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 be Dose #2 Dose #3 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. Student Signature ***SECTION 2 MUST BE COMPLETED AND SIGNED BY PHYSICIAN OR HEALTH CARE PROVIDER FOR ALL STUDENTS*** PHYSICIAN/HEALTH CARE PROVIDER PLEASE COMPLETE ALL ITEMS LISTED BELOW If this person was born January 1, 1957 or later they are required by New York State law to provide proof of immunity as follows: MEASLES VACCINE, 1968 or later and on or after first birthday. Two doses of live vaccine are required at least thirty (30) days apart. Dose #1 _ Dose #2 _ OR MMR Dose 1 Dose 2 _ OR physician diagnosed disease OR positive measles blood titer test MUMPS VACCINE, 1969 or later and on or after first birthday. _ OR physician diagnosed disease OR positive mumps blood titer test RUBELLA VACCINE ***Required regardless of age***, 1969 or later and on or after first birthday. _ OR positive rubella blood titer test Td or TDAP (please circle one) ***Required within 10 years*** Influenza Vaccine (this may be required by your clinical site): PPD SKIN TEST ***Required within one year*** : : Step 1: Given: Read: Result: Pos Neg PPD Step 2: Given: Read: Result: Neg Pos ***Positive PPD, must supply chest X-ray*** : Result (circle one): Normal Abnormal Healthcare Provider Signature/Stamp Page 7

10 STUDENT ID SECTION 2 CONTINUED TO BE COMPLETED BY PHYSICIAN OR HEALTH CARE PROVIDER Height: Weight: Blood Pressure: / Uncorrected Vision: OR Corrected Vision R / L / R / L / AREA EXAMINED NORMAL ABNORMAL NOT EXAMINED DESCRIBE ABNORMAL FINDINGS HAND/SKIN Hair Skin/Color/Texture/Hydration Nails Tattoos/Scars HEAD/EYES Lids Conj/Sclera Pupils/Equal/Light Reaction Fundi Extracular Movements EARS/NOSE/THROAT/MOUTH Pinna/Canals/Tympanic Membrane Nasal Septum/Mucosa Teeth/Gums Tongue/Palate Tonsils/Pharynx NECK/NODES Bruit Range of Motion Muscle Strength Thyroid Neck Nodes Inguinal/Axillary Nodes CHEST/LUNGS Shape Percussion Ausculation Breast (Discharge/Masses) CARDIOVASCULAR Carotid Arteries Neck Veins Apical Impulse Heart Murmurs Heart Size Page 8

11 STUDENT ID SECTION 2 CONTINUED AREA EXAMINED NORMAL ABNORMAL NOT EXAMINED ABDOMEN Scars Bowel Sounds Organomegaly Tenderness Guarding Masses Hernia MUSCULOSKELETAL/EXTREMITIES Extremities (Edema/Varicosity) Joints/Amputations Range of Motion Pulses MUSCULOSKELETAL/SPINE Spinal Alignment/Scoliosis Joints Range of Motion NERVOUS SYSTEM Cranial Nerves Motor Sensory Reflexes GENITALIA/RECTAL MALE: Penis Scrotum/Testes (hernia) Prostate/Rectum FEMALE: Perineum/Vagina Cervix/Uterus/Adnexa DESCRIBE ABNORMAL FINDINGS Page 9

12 STUDENT ID SECTION 3 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 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: SECTION 3 PHYSICIAN OR HEALTH CARE PROVIDER, carefully read the following statement, and check the appropriate boxes. 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 OFFICE FAX # (IF APPLICABLE) PHYSICIAN S TELEPHONE NUMBER DATE OF EXAM (Must be within one year of entering program) RETURN TO: MONROE COMMUNITY COLLEGE HEALTH SERVICES DEPARTMENT 1000 EAST HENRIETTA RD. ROCHESTER, NY PHONE: , FAX Page 10