HARFORD COMMUNITY COLLEGE
401 Thomas Run Road
Bel Air, Maryland 21015
443-412-2000
Date of Exam:
_____
Program of Study:
_____
DIVISION OF NURSING AND ALLIED HEALTH PROFESSIONS
MEDICAL HEALTH EXAMINATION RECORD
This report is confidential. Students are responsible for the accuracy of this information. Omitted or inaccurate information will be considered a
violation of the HCC Honor Code and can result in a student’s dismissal from the program.
To be completed by student:
Name:
Address (include city, state, zip):
Emergency Contact:
DOB:
Sex:
Telephone:
Student ID#
Email:
Telephone:
 Male
 Female
Relationship:
I hereby grant the health professions program permission to contact the physician(s) or other professional(s) who have assisted me
with medical conditions, mental health conditions, alcoholism, and/or drug dependency and to obtain information and records
regarding these conditions.
Student’s signature
To be completed by Physician:
Date:
(Use back of form if needed for notes and explanations.)

Student must be free of contagion and possess sufficient physical stamina with or without reasonable accommodations, and possess
mental stability to fulfill the requirements of the program and the customary requirements of the profession.

Work 10-12 hours performing physical tasks requiring physical energy without jeopardy to patient and student safety, e.g. bending,
lifting, turning, and ambulating adult patients.

Perform fine movements and be able to manipulate instruments and equipment.

Establish and work towards goals in a consistently responsible realistic manner.

Have auditory ability sufficient to monitor and assess health needs.

Have visual ability for observation and assessment necessary for patient care.

Possess the emotional maturity and stability to approach highly stressful human situations in a calm and rational manner.
1. The applicant has been examined and found to be in good general health. _____ Yes
______ No (explain please)
2. Is the applicant currently under medical treatment? _____ Yes (specify condition being treated)
______ No
3. Has applicant had any major illness in the past year requiring on-going care or therapy by a health professional?
____ Yes (explain please)
____ No
4. Chronic conditions (please list):
5. Has applicant had any hospitalizations, injuries, restriction of physical activity within last five years? Give dates and specify problem:
6. The applicant is fit to participate in the clinical activities of an allied health care program. _____ Yes
_____ No (explain please)
7. To the best of my knowledge, the applicant is not presently harboring any infectious diseases. _____ Correct
8. Has applicant had any mental health problems?
_______ Yes (explain please)
_____ Incorrect (explain please)
______ No
9. Has applicant had any drug or alcohol dependency? _____ Yes (specify problems and dates)
______ No
10. Allergies -- include sensitivity/allergy to chemicals, dust, latex, etc.(please list):
11/13
PHYSICIAN------ CONTINUE ON BACK
STUDENT NAME (printed)
Antibody titer –
Required Immunization
OR ➙
Dates Immunizations Received
Hepatitis (Hep B)
Report 3 doses or titer results
Varicella (Chicken Pox)
Report 2 doses after age 12 months or titer results
Measles (Rubeola)
Report 2 doses after age 12 months or titer results
Mumps
Report 2 doses after age 12 months or titer results
Rubella (German Measles)
Report 2 doses after age 12 months or titer results
Tetanus/Diphtheria (Td or Tdap)
Report most current Td dose (within 10 years)
If it has been at least 2 years since the last Td dose, and you
have never had a Tdap, a Tdap is REQUIRED.
Required TST (Tuberculin Skin Test)
Mantoux Required (PPD)
Dose 1 Date
Dose 2 Date
Dose 1 Date
Dose 2 Date
Test Date
Dose 1 Date
Dose 2 Date
Test Date
Dose 1 Date
Dose 2 Date
Test Date
Dose 1 Date
Dose 2 Date
Test Date
Dose Date – Td
Dose Date – Tdap
Administration Date:
Last PPD Test Date
if Positive
Test Date
Date Read:
Induration:
Individuals with a previous positive PPD
Must provide date of last PPD and a copy of chest x-ray report
within the last six months OR official documentation of a history
or tuberculosis and completion of treatment.
Seasonal flu vaccine
Dose 3 Date
MUST Attach
Lab Results
mm
_____ Chest x-ray report attached
_____ Documentation of disease history and completion of
treatment attached.
Dose Date
I certify that I am a primary health care provider legally qualified to practice in the State of
.
I have examined the above applicant and find that the applicant is neither mentally nor physically disqualified by reason of acute,
chronic, or mental conditions from the successful performance of the clinical duties required of health sciences students.
Health Care Provider’s Signature
Date
Address
Phone
Health Care Provider’s Name (Printed or Stamped)
HEALTH EVALUATION IS NOT VALID WITHOUT PHYSICIAN’S SIGNATURE
EXPLANATIONS – FOR PHYSICIAN USE