School of Nursing Health Form
Appendix B
CUMBERLAND UNIVERSITY
Jeanette Cantrell Rudy Division of Nursing
Student / Instructor Health Form
________________________________________________________________
Last Name First MI
Home Address
____________________________________________________________________
Street City State Zip Code
_____________ __________________ ___ _____________ _________ ________
Date of Birth Social Security No. Sex Marital Status Home Phone Work Phone
________________________________________________________________________
Name of Health Insurance Company & Group/Policy Number(s)
____________________________________________________________ ___________
Name of Parents, Guardian, or Spouse (Address & Phone if Different From Above Phone
________________________________________________________________________
IMMUNIZATIONS/TITERS REQUIRED
HEPATITIS B VACCINE
Dose # 1
HEALTH CARE
DATE Provider's Initial
_____ __________
Dose # 2 (to be given 1 month after the 1 st injection) ______ ____________
Dose # 3 (to be given 6 months after the 1 st injection) ______ ____________
TETANUS (within the last 10 years) ______ ____________
**MUMPS TITER (attach copy of lab report)
**RUBEOLA (Red Measles) TITER (attach copy of lab report)
**RUBELLA (German Measles) TITER (attach copy of lab report)
**VARICELLA TITER (attach copy of lab report)
***HEPATITIS B TITER (attach copy of lab report)
**This titer must include IGG antibody levels.
***This must be a QUANTITATIVE TITER and is to be drawn 30-60 days after the third injection.
_______________________________________________________________________________________
PAST MEDICAL/SURGICAL HISTORY
Have you had surgery? List surgery dates. _____________________________________________________________
______________________________________________________________________________________
Have you been treated for any serious illness? Give details_________________________________________________
Are you presently on any medication? If so, list medication(s).______________________________________________
Have you been treated for any psychological/emotional problems? Give details. ________________________________
Is there a family history of a bleeding disorder, cancer, hypertension or diabetes? List and state relationship . ________
_______________________________________________________________________________________
Do you have any current health problems/limitations that will affect your ability to function as a nursing student? Give details
__________________________________________________________________________________________
________________________________________________________________________________________________
CHILDHOOD DISEASES
Have you ever had: MUMPS: Yes No
MEASLES: Yes No
CHICKEN POX: Yes No SCARLET FEVER:
DIPTHERIA: Yes No GERMAN MEASLES:
Yes No
Yes No
NOTE TO HEALTH CARE PROVIDER: Health examination form may be completed by a physician, nurse practitioner or a licensed physician’s assistant.
PHYSICAL EXAMINATION
Age________ Height________
Normal
Weight________ Blood Pressure________
Abnormal Comments
Eyes
Ears
Nose and Throat
_____
_____
_____
Sinuses _____
Mouth and Teeth _____
Chest _____
Heart _____
Abdominal Viscera _____
Endocrine Viscera _____
Nervous System _____
Lymphatic Glands _____
Orthopedic Defects _____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
LABORATORY TESTING
URINALYSIS: Protein________ Sugar________ Blood________
CBC (attach lab report): Date________
TB SKIN TEST #1 Date__________ TB SKIN TEST RESULT: ________ Date Read: ___________
TB SKIN TEST #2 Date __________ TB SKIN TEST RESULT ________ Date Read: ___________
CHEST X-RAY (if positive skin test): Date________ Results_____________________
Examiner’s Signature___________________________
Date_______________________
ADDITIONAL INFORMATION
In case of serious illness or accident, I give Cumberland University or its representative(s) permission to secure medical and/or surgical care to include transportation to a doctor or hospital of their choice, injections, examinations, medication, and surgery that is considered necessary for my good health. I agree to pay all medical costs.
Signature of Student _____________________________ Date_____________________
Parent or Guardian (if under age 18)_______________________ Date________________
Please note your admission process is not complete until completed form is received.
