Gaston College Health and Human Services Division Student Medical Form

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1 Student Name: : Gaston College Health and Human Services Division Student Medical Form Associate Degree Nursing Cosmetology Dietetic Technician and Dietary Manager Health and Fitness Science Medical Assisting Nursing Assistant Phlebotomy Practical Nursing Therapeutic Massage Veterinary Medical Technology

2 Gaston College Health and Fitness Science Program Health Form Requirements All seven (7) pages, including the Student Medical Form cover page must be turned in on or before August 2, 24. When completing the Gaston College Health and Fitness Science Health Form, please note these additional instructions: On Page : (Cover page) Print your name and date completed On Page : Please use your Gaston College student ID number not your social security number. Complete entire Family and Personal Health History. If you check yes to any condition you MUST include the year of first occurrence. On Page 4: Complete history and be sure to sign and date to bottom of page 4. On Page 6: Be sure your name and date of birth are at the top of this page. Health care provider must sign and date at the bottom of page. Section A: a. MMR there must be proof of two (2) doses after 2 months of age OR a positive antibody titer. b. Proof of a history of three () DTP or Td, one () of which must be a TDaP (Tetanus, Diphtheria, and Pertussis) Proof of immunization within the last ten () years. You may provide proof that you attended a North Carolina public primary school or university if you are unable to provide proof of DTP history, but must still have a TDaP within last ten years. Your health care provider MUST note that you have received a TDaP, not just a Td. Section B: a. All of Section B is REQUIRED for Health and Fitness Science students. b. Varicella there must be proof of two (2) doses OR a positive antibody titer. (History of disease is not acceptable proof) c. Students must complete a 2-step PPD test within the past 64 days (less than one year). This consists of 2 PPD tests, not just one! Section C: These immunizations are not required, but are strongly recommended. On Page 7: a. Physical Exam ALL sections on this page are required. Vision, Hearing, Urinalysis, Hgb (or Hct) are REQUIRED by Gaston College Health and Fitness Science. Be sure your health care provider includes height, weight, temperature, pulse, respiration and blood pressure on this page. b. Please note the box marked This section must be completed for students admitted to Health Education Program. This box MUST be completed. Non-completion will result in returning the health form to the student to return to the healthcare provider for completion. My signature below acknowledges that I have read the directions for completing the Student Medical Form for the Health and Fitness Science program. I understand that failure to have this form completed by the stated due date may result in my being removed from the ADN program. Student Signature 2

3 REPORT OF MEDICAL HISTORY to be completed by student LAST NAME (print) FIRST NAME MIDDLE/MAIDEN NAME STUDENT ID NUMBER PERMANENT ADDRESS CITY STATE ZIP CODE PHONE NUMBER DATE OF BIRTH (MM/DD/YR) GENDER M F MARITAL STATUS S M OTHER SEMESTER ENTERING (circle): FALL SPRING SUMMER YEAR 2 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. FAMILY & PERSONAL HEALTH HISTORY Has any person, related by blood, had any of the following: to be completed by student Yes No Relationship Yes No Relationship Yes No Relationship 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 HEIGHT WEIGHT 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 Frequent or severe headache Bone, joint or other deformity Rheumatic fever Dizziness or fainting spells Knee problems Heart trouble Concussion Recurrent back pain Pain or pressure in chest Severe head injury Neck injury Shortness of breath Paralysis Back injury Asthma Disabling depression Bladder infection Pneumonia Excessive worry or anxiety Kidney infection Chronic cough Ulcer (duodenal or stomach) Kidney stones Malaria Intestinal trouble Protein or blood in urine Thyroid trouble Jaundice or hepatitis Hearing loss Diabetes Rectal disease Anorexia/Bulimia Serious skin disease Hernia Severe menstrual cramps Mononucleosis Easy fatigability Irregular periods Tumor or cancer (specify) Anemia or sickle cell anemia Wear seat belt Arthritis Sexually transmitted diseases A regular exercise regime Hay fever Blood transfusion Alcohol use Allergy injection therapy Pilonidal cyst Drug use Sinusitis Frequent vomiting Smoke + pack cigarettes/wk Eye trouble (besides corrective lenses) Gall bladder trouble or gallstones Broken bone (specify) Head or neck radiation treatments Severe or recurrent abdominal pain Other (specify) 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. Name Dosage/day Reason for taking started Name Dosage/day Reason for taking started Name Dosage/day Reason for taking started Name Dosage/day Reason for taking started Name Dosage/day Reason for taking started Name Dosage/day Reason for taking started

4 FAMILY & PERSONAL HEATH HISTORY-CONTINUED to be completed by student Check each item Yes or No. Every item checked Yes must be fully explained in the space on the right (or on an attached sheet). Have you ever experienced adverse reactions (hypersensitivities, allergies, upset stomach, rash, hives, etc.) to any of the following? If yes, please explain fully the type of reaction, your age when the reaction occurred, and if the experience has occurred more than once. Adverse Reactions to: Yes No Explanation Penicillin Sulfa Other antibiotics (name) Aspirin Codeine Other pain relievers Other drugs, medicines, chemicals (specify) Insect bites Food allergies (specify) Latex allergy Do you have any conditions or disabilities that limit your physical activities? (If yes, please describe) Yes No Explanation Have you ever been a patient in any type of hospital? (Specify when, where, and why) Has your academic career been interrupted due to physical or emotional problems? (Please explain) Is there loss or seriously impaired function of any paired organs? (Please describe) Other than for routine check-up, have you seen a physician or health-care professional in the past six months? (Please describe) Have you ever had any serious illness or injuries other than those already noted? (Specify when and where and give details) IMPORTANT INFORMATION PLEASE READ AND COMPLETE STATEMENT BY STUDENT (OR PARENT/GUARDIAN, IF STUDENT UNDER AGE 8): I have personally supplied (reviewed) the above information and attest that it is true and complete to the best of my knowledge. I understand that the information is strictly confidential and will not be released to anyone without my written consent, unless otherwise permitted by law. If I should be ill or injured or otherwise unable to sign the appropriate forms, I hereby give my permission to the institution to release information from my (son/daughter s) medical record to a physician, hospital, or medical professional involved in providing me (him/her) with emergency treatment and/or medical care. Signature of Student Signature of Parent/Guardian, if student under age 8 4

5 GUIDELINES FOR COMPLETING IMMUNIZATION RECORD IMPORTANT The immunization requirements must be met; or according to NC law, you will be withdrawn from classes without credit. Acceptable Records of Your Immunizations May be Obtained from Any of the Following: (Be certain that your name, date of birth, and ID Number appear on each sheet and that all forms are submitted together. The records must be in black ink and the dates of vaccine administration must include the month, day, and year. Keep a copy for your records.) High School Records These may contain some, but not all of your immunization information. Your immunization records do not transfer automatically. You must request a copy. Personal Shot Records Must be verified by a doctor s stamp or signature or by a clinic or health department stamp. Local Health Department Military Records or WHO (World Health Organization documents) Previous College or University Your immunization records do not transfer automatically. You must request a copy. SECTION IMMUNIZATION REQUIREMENTS ACCORDING TO AGE A: STUDENTS 7 YEARS OF AGE AND YOUNGER DTP/Td/TDaP Polio Measles 2 2 STUDENTS BORN IN 957 OR LATER AND 8 YEARS OF AGE OR OLDER DTP/Td/TDaP Polio Measles 2, 2 Mumps Mumps Rubella Rubella STUDENTS BORN BEFORE 957 or earlier DTP/Td/TDaP Polio Measles Mumps Rubella. DTP (Diphtheria, Tetanus, Pertussis), Td (Tetanus, Diphtheria). If you are unable to provide proof of three () DTP or TD immunizations, you may provide proof that you attended a North Carolina public primary school or university as proof of immunizations. One TDaP (Tetanus, Diphtheria, Pertussis) booster within the last ten () years. 2. Measles: One dose on or after 2 months of age; second at least days later. Must repeat Rubeola (measles) vaccine if received even one day prior to 2 months of age. History of physician-diagnosed measles disease is acceptable, but must have signed statement from physician.. One does on or after 2 months of age. Only laboratory proof of immunity to rubella or mumps disease is acceptable if the vaccine is not taken. History of rubella or mumps disease, even from a physician, is not acceptable. 5

6 IMMUNIZATION RECORD To be completed by Physician/Physician Assistant/Nurse Practitioner or clinic. A complete immunization record from a physician or clinic may be attached to this form. Last Name First Name Middle Name of Birth (mo./day/year) Student ID# SECTION A REQUIRED IMMUNIZATIONS mo./day/year mo./day/year mo./day/year mo./day/year DTP or Td (#) (#2) (#) (#4) TDaP booster (within last ten [] years) Polio MMR (after first birthday) MR (after first birthday) Measles (after first birthday) *Disease Mumps **Disease date NOT accepted Rubella **Disease date NOT accepted The following immunizations are recommended for all students and may be required by certain departments (for example Health and Fitness Science). Please consult your program department materials for specific requirements. SECTION B REQUIRED IMMUNIZATIONS mo./day/year mo./day/year mo./day/year Hepatitis B series only (#) (#2) (#) OR Hepatitis A/B combination series (#) (#2) (#) Varicella (chicken pox) series of two doses or immunity by positive blood titer Influenza (flu) required annually by some clinical facilities Tuberculin (PPD) Test read (within 2 months) mm induration Chest x-ray, if positive PPD Results Treatment if applicable TB Screening Form annually for those with previous positive PPD skin test and clear chest x- ray (#) (#2) SECTION C OPTIONAL IMMUNIZATIONS mo./day/year mo./day/year mo./day/year Pneumococcal Hepatitis A series only Meningococcal Signature or clinic Stamp REQUIRED: Signature of Physician/Physician Assistant/Nurse Practitioner Print Name of Physician/Physician Assistant/Nurse Practitioner Area Code/Phone Number Office Address City State Zip Code * Must repeat Rubeola (measles) vaccine if received even one day prior to 2 months of age. History of physician-diagnosed measles disease is acceptable, but must have a signed statement from physician. ** Only laboratory proof of immunity to rubella or mumps is acceptable if the vaccine is not taken. History of rubella or mumps disease, even from a physician, is not acceptable. *** Attach lab report 6

7 PHYSICAL EXAMINAION To be completed and signed by Physician/Physician Assistant/Nurse Practitioner or clinic A physical examination is required by Health Education programs (consult your program department for specific requirements). Form must be completed in black ink and signed by a physician or clinic. Last Name First Name Middle Name of Birth (mo/day/year) Permanent Address City State Area Code/Phone Number Height Weight TPR / / BP / ALL REQUIRED: ALL REQUIRED: Vision: Corrected Right 2/ Left 2/ Urinalysis Sugar: Albumin Uncorrected Right 2/ Left 2/ Micro Color Vision Hgb (or Hct) Hearing: (gross) Right Left 5 ft. Right Left Are there abnormalities? Normal Abnormal DESCRIPTION (attach additional sheets if necessary). Head, Ears, Nose, Throat 2. Eyes. Respiratory 4. Cardiovascular 5. Gastrointestinal 6. Hernia 7. Genitourinary 8. Musculoskeletal 9. Metabolic/Endocrine. Neuropsychiatric. Skin 2. Mammary A. Is there loss or seriously impaired function of any paired organs? Yes No B. Is student under treatment for any medical or emotional condition? Yes No C. Recommendation for physical activity (physical education, intramurals, etc.) Unlimited Limited D. Is Student physical and emotionally healthy? Yes No E. Does student have a latex allergy Yes No This section must be completed for students admitted to Health and Fitness Science Program Based on my assessment of this applicant s physical and emotional health on, he/she demonstrates evidence that is indicative of his/her ability to provide safe health and fitness prescription to the public. Yes No if no, please explain: Signature of Physician/Physician Assistant/Nurse Practitioner Print Name of Physician/Physician Assistant/Nurse Practitioner Area Code/Phone Number Office Address City State Zip Code 7

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