PR I N C E G E O R G E ’S
COMMUNITY COLLEGE
Prince George’s Community College
Division of Health, Wellness &
Hospitality
Health Assessment Requirements
A health assessment, completed by a physician, is required for
each Allied Health and Nursing student. Most of our clinical sites
are requiring evidence of immunization and a current PPD test in
order to meet The Joint Commission standards for all employees,
volunteers, and students. If a student’s health assessment is not
current, clinical placement may be denied by the agencies.
In order for you to proceed without any interruptions to your
clinical program, you must have a health assessment performed.
All health assessment information released to the specific Allied
Health or Nursing Program is retained in the student’s file by the
program. Any information about you will remain confidential and
will only be shared with the requesting clinical agency. It will be
the clinical agency, not the College that will make any final
determinations about your placement. If you have any questions,
please contact your program director.
Revised July 28, 2021
Name:
Program Name:
PRINCE GEORGE'S
COMMUNITY COLLEGE
Last
First
DIVISION of
HEALTH
WELLNESS &
HOSPITALITY
Health Assessment Record
Student ID#
_
Date of Birth
Name
(Last)
Phone
(Home)
(First)
Gender (M/F)
(Work)
Street
City
Rev. 7/28/21
Page 1
State
Name:
Date:
Zip
Directions:
This form is required of each Allied Health or Nursing student enrolled in a clinical program. It is intended to assess the general health
and immunization status of the student, and to verify that the student meets minimum health requirements and technical standards
necessary to perform essential duties in the clinical area.
The Health Assessment Form is in compliance with Prince George’s Community College’s policy of equal opportunity and
nondiscrimination, and the Americans with Disabilities Act of 1989.
Part I “Personal Health History” is to be completed by the student. Part II “Technical Standards” and Part III “Laboratory Studies and
Immunization Status” are to be completed by the examiner. All information is confidential and will not be disclosed to any party without
permission of the student.
I consent to the disclosure of the information on this form to the Division of Health, Wellness & Hospitality of PGCC.
(Student Signature)
PART I. Personal Health History:
Chicken Pox
Rubeola (10-day measles)
Rubella (German measles)
Mumps
Tuberculosis
Rheumatic Fever
Hearing problems
Vision problems
Glasses/contacts
Seizure/convulsions
Allergies
Chest pain/angina
Heart disease
(Date)
Check (√) either yes or no in the “Now” column AND the “Past” column.
NOW
Yes No
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PAST
Yes No
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Shortness of breath
High blood pressure
Hepatitis
Thyroid problems
Diabetes
Kidney disease
Orthopedic problems
Back problems/injury
Arthritis
Cancer
Anemia
Bleeding tendency
Drug/Alcohol dependency
(palpitations; arrhythmias)
If “yes” to any of the above, explain:
Rev. 7/28/21
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Date:
NOW
Yes No
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PAST
Yes No
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Do you carry hospitalization/medical insurance? Yes  No 
The student is financially responsible for any injury or illness sustained while on campus or at the clinical site. First aid and appropriate referrals
are provided by the Wellness Center, Bladen Hall, Room 132. Consult individual health science programs’ Student Manual for the proper
procedures for reporting an incident.
Medications taken regularly (over-the-counter and prescription):
Any major illness in past year requiring on-going care or therapy by a health professional? Yes
Explain
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No
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Any hospitalizations, injuries, restriction of physical activity? Give dates and specify problem:
Currently under Medical treatment? Yes 
No 
Specify condition being treated and name and address of health professional consulted:
Have you had any mental health problems? Yes
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No
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If yes, please specify problem and date(s)
Professional consulted:
Name:
Address:
Date:
Do you grant permission to the Wellness Center staff and health sciences faculty to contact physicians or other professionals who have assisted
you with medical and/or mental health problems? Yes  No 
Student’s signature
Date:
Student’s Acknowledgement
I hereby acknowledge that the personal health history information is true and complete to the best of my knowledge and nothing has been omitted
which would interfere with my physical and/or mental ability to perform assigned functions in my clinical area.
Student’s signature
Date:
If after reviewing the candidate’s Health Assessment Record, the health sciences program has questions regarding the candidate’s ability to meet the
technical standards, the program may refer the student back to their primary physician for a more detailed summary and/or refer the candidate to the
Disabilities Support Services Office to document their disability (if any) and to request academic accommodations to ensure equal access in program
participation. Students can contact the Disability Support Services Office (L-101A), dss@pgcc.edu or call (301) 546-0838 (voice) or (301)
546-0122 (TTY) to establish eligibility for services and academic accommodations. If eligible for services, the Disability Support Services Office
will provide the candidate with a Student/Faculty Accommodation Form which must be submitted to the program faculty prior to the start of the
semester in order to receive requested accommodation(s).
3
PART II. Students: Place a checkmark by your health program. If you are unable to comply with the technical standards,
describe, on a separate sheet of paper, what reasonable accommodations are necessary.
Examiner: Please review the appropriate technical standards and evaluate as part of your assessment.
Technical Standards for the Health Information Management Program
Yes
No
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(1) Work up to 8-10 hours performing physical tasks such as walking, sitting, lifting, bending, and turning.
(2) Perform fine motor movements needed to manipulate instruments and equipment.
(3) Communicate effectively, using auditory and visual skills.
(4) Establish and work toward goals in a consistently responsible manner.
Technical Standards for the Medical Assisting, Paramedic, Nuclear Medicine, Nursing, Radiography, and Respiratory Therapy and Surgical
Technology Programs (Circle program)
*Standard 8 applies only to the Radiography and Nuclear Medicine Programs.
Yes
No
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(1) Work up to 8-10 hours performing physical tasks such as walking, sitting, lifting, bending, and turning.
(2) Perform fine motor movements needed to manipulate instruments and equipment.
(3) Communicate effectively, both verbally and written, with peers, patients, and physicians.
(4) Monitor and assess patient’s needs using auditory and visual skills.
(5) Work as a member of the health care team to care for patients while maintaining
high standards of professionalism.
(6) Work safely with patients who are susceptible to or are in the contagious stage(s) of communicable disease(s).
(7) Establish and work toward goals in a consistently responsible manner.
*(8) Monitor radiation exposures by the visual and auditory mode, while delivering ionizing radiation.
Health Assessment (within the last six months)
How long has this person been under your care?
Date of last health assessment/physical exam
Please check all items:
Normal Abnormal
Posture
Head and neck (include thyroid)
Nose
Mouth
Throat and tonsils
Ears (include auditory acuity)
Eyes (include visual acuity)
Lungs and chest (include breasts)
Heart
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Normal
Abdomen (include hernia)
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Pelvic with Pap Smear (optional/Female) 
Testicular exam (Male)
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Spine and musculoskeletal system
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Skin and lymph nodes
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Neurologic
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Mental status (recent memory,
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calculating ability, orientation)
Abnormal or significant findings, including pregnancy
Rev. 7/28/21
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Name:
Date:
Abnormal
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PART III.
Laboratory Studies and Immunization Status
(Documentation indicating result, action and date required)
1.
Hepatitis B Vaccine: (Required)
Dates:
#1
/
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#2
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#3
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6. TB Test: (2 step TB procedure - required annually)
a. TB test (Mantoux PPD):
#1 PPD Planted:
#1 PPD Read:
Titer Results (HBs Ab):
Date:
/
/
2. Measles, Mumps, Rubella (MMR) Immunization:
Titers indicating immunity will be accepted in lieu of
MMR immunization.
a.
Two MMR’s or titers showing immunity is required.
#1
/
/
#2
/
/
b.
Rubeola (measles) Titer:
Immune □
non-immune □
c.
Mumps Titer:
/
/
Immune □
non-immune □
d.
Rubella (German Measles)
Titer:
/
/
Immune □
non-immune □
/
/
4. Polio Titer: Date:
Immune □
/
/
/
/
non-immune □
/
/
mm duration
/
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NOTE: A history of positive PPD skin test requires:
a. Documented Negative CXR within 5 years
Date:
/
/
and
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gm/dL (within last 6 months)
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8. Urinalysis: (within 6 months)
Glucose: negative □ positive □
Protein: negative □ positive □
Date:
/
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5. Varicella: (Chicken Pox)
(Will not accept self-reporting, must have titer or
immunizations)
Varicella Immunization:
#1
/
/
#2
/
b. CXR: (required for current positive reaction)
Normal □ abnormal □
Date:
/
_/
7. Hemoglobin:
Date:
/
/
non-immune □
Varicella Titer: Date:
Immune □
/
mm duration
/
/
b. Annual Review of TB symptoms by health care
provider:
Positive □ Negative □
Date:
/
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3. Tetanus/Diphtheria/Pertussis (T-DAP):
(required within last 10 years)
Date of last booster:
TB Test (Mantoux PPD):
#2 PPD Planted:
#2 PPD Read:
/
9. Current Seasonal Flu Vaccine:
Date given:
/
/
Type:
Lot #_
Exp. Date
_/
/
NOTE: Immunization requirements are subject to change based on
policy changes of the clinical facilities.
/
This student is cleared on the basis of the personal history, health assessment, immunizations, and laboratory test results to
participate in clinical laboratory experience. [The examiner can be a physician (MD) or certified nurse practitioner (CNP)].
(Examiner’s signature)
(Date)
(Type or print examiner’s name)
Rev. 7/28/21 Page 5
(Office telephone)
Name:
Date: