COCHISE COLLEGE
PARAMEDIC PROGRAM
Paramedic Program
Student Profile
Student Information
Full Name:
Last
First
M.I.
Address:
Street Address
Apartment/Unit #
City
Home Phone:
State
(
)
(
Alternate Phone:
ZIP Code
)
E-mail Address:
Student ID Number (“C” number):
Employment Information
Title:
Company:
Supervisor:
Department:
Work Location:
E-mail Address:
(
Work Phone:
)
Cell Phone:
(
)
Emergency Contact Information
Full Name:
Last
First
M.I.
Address:
Street Address
Apartment/Unit #
City
Primary Phone:
State
(
)
Alternate Phone:
(
ZIP Code
)
Relationship:
_________________________________________________________________________________________________________
____________
Candidate Registration Packet\physical
1
COCHISE COLLEGE
PARAMEDIC PROGRAM
Cochise College Paramedic Program
History and Physical
FOR THE STUDENT:
This form must be completed and submitted with our application packet to the Nursing / Allied
Health Department Office, Cochise College, 901 North Colombo Avenue, Sierra Vista, AZ 85635. The
physical examination must be current - within one (1) year – of the class start date. Reentering
students must submit a current medical history and report of physical examination.
TO STUDENTS AND HEALTH EXAMINERS:
Paramedic students are preparing for an exacting profession in which they must take responsibility
for the lives and well-being of others. Applicants must be in good physical and mental health;
otherwise, they may be denied admission or, once admitted, recommended for withdrawal.
CONFIDENTIALITY:
All information given on this form will be kept confidential and is intended solely to ensure that the
student can participate in all required activities of the Paramedic Program. Program Faculty will have
access to this information as necessary. Health agencies where the student might be assigned may
have access to this information if they request it. The Nursing / Allied Health Department reserves
the right to request additional information if deemed necessary.
This physical form is comprised of two parts:
Part One:
Medical History is to be completed by the student.
Part Two:
Report of Physical Examination is to be completed by a licensed Health
Examiner.
PART ONE:
MEDICAL HISTORY
completed by STUDENT
Please print clearly:
Name: ______________________________________________________________________________
Mailing Address: ______________________________________________________________________
Permanent Address: ___________________________________________________________________
Telephone Number: (
) ___________________(present)
(
) ___________________(permanent)
DOB: __ __ /__ __ / __ __ __ __ Sex: __ M __ F Cochise College #: C __ __ - __ __ - __ __ __ __
Medical Insurance: ____________________________________________________________________
Cochise College E-mail address: ________________________________@students.cochise.edu
Personal E-mail address: ________________________________@___________________________
_________________________________________________________________________________________________________
____________
Candidate Registration Packet\physical
2
COCHISE COLLEGE
PARAMEDIC PROGRAM
1.
List any current restrictions of physical activity.
2.
List any illness or condition for which you are now under treatment (physical or psychological).
3.
List medications you are currently taking.
4.
List any allergies.
5.
List past surgeries, hospitalizations, injuries, or major illnesses (with dates) which may affect
your ability to function physically in the Paramedic Program. (i.e., lifting restrictions due to a
prior back injury)
6.
List any mental, emotional or nervous condition for which you were ever under professional
care? (i.e., psychiatrist, psychologist, mental health clinic) List dates.
7.
List any mental, emotional or nervous condition for which you are currently under professional
care. In what way could these problems affect your ability to function in the Paramedic
Program?
8.
List any problems with drug abuse, including alcohol. Please list details and dates.
9.
Have you ever been refused employment for health reasons?
10.
Have you ever been disqualified for duty in the Armed Forces, or discharged for medical
reasons?
If so, what was the nature and percentage of disability?
I, the undersigned, when applying for admission to the Cochise College Paramedic Program, do hereby
certify that the answers to the above questions are true, complete and accurate. I understand that a
false statement or omission would be considered sufficient cause for dismissal. I understand that any of
the above information may be provided to Paramedic faculty and health agencies if deemed necessary.
_______________________________________ ___________
Student signature
Date
I, the undersigned, if pregnant, or should I become so, agree to notify my clinical coordinator, whether
or not I am under any restriction. The clinical coordinator will decide if I will be able to meet the
requirements of the program.
_______________________________________ ___________
Student signature
Date
I understand that by withholding information I could jeopardize patient safety and will be held
accountable under the policies and procedures of the Paramedic Program.
_______________________________________ ___________
Student signature
Date
_________________________________________________________________________________________________________
____________
Candidate Registration Packet\physical
3
COCHISE COLLEGE
PARAMEDIC PROGRAM
PART TWO: REPORT OF PHYSICAL EXAMINATION
completed by Licensed Health
Examiner
Please fill in all areas of this form. Admission to the program is based on a complete physical form.
ALL QUESTIONS MUST BE FILLED IN to meet the requirements of the Arizona State Health
Department, and of local health care agencies. Liability occurring as a result of inaccurate information
on this form will rest with the completer of the form.
PHYSICAL STATISTICS:
Height: ________
Weight: ________
Blood Pressure: ________
Pulse: _______
Respiration: __________ Temperature: __________ Vision: __________ Hearing: _________
(Snellen Chart)
Normal
(gross) (whisper
heard at 3 ft.)
Abnormal
EENT
Cardiovascular System
Respiratory System
G.I. System
G.U. System
Neuromuscular System
Musculoskeletal System
(any abnormalities of the spine must be specified. For
patient safety, student cannot have a lifting restriction. If
there are any questions about this, please have the student
contact the Paramedic Program for advisement.)
Endocrine
Integumentary System
Neurological System
Functional Abilities
(Please see reverse side examples.)
_________________________________________________________________________________________________________
____________
Candidate Registration Packet\physical
4
Functional Abilities Essential for Paramedic Duties
Category
Description
Examples of Necessary Activities
(not all inclusive)
Gross motor skills sufficient to provide
the full range of safe & effective
PARAMEDIC care activities

Move within confined spaces

Reach above shoulders
Fine motor skills sufficient to perform
manual psychomotor skills

Pick up objects with hands

Grasp small objects with hands
Physical endurance
Physical stamina sufficient to perform
client care activities for entire length of
work role

Maintain physical tolerance for
and work entire shift
Physical strength
Physical strength sufficient to perform
full range of required client care
activities

Push & pull 25 pounds

Move heavy objects weighing
from 11-50 pounds
Physical abilities sufficient to move from
place to place and maneuver to perform
PARAMEDIC activities

Twist

Bend

Stoop/squat

Move quickly

Hear normal speaking level
sounds

Hear faint body sounds

Hear auditory alarms (monitors,
fire alarms, call bells)
Visual ability sufficient for accurate
observation and performance of
PARAMEDIC care

See objects up to 20 feet away

Distinguish color
Tactile ability sufficient for physical
monitoring and assessment of health
care needs

Feel vibrations (pulses)

Detect temperature changes
Smell
Olfactory ability sufficient to detect
significant environmental and client
odors

Detect odors from client (foul
smelling drainage, alcohol
breath, etc.)
Emotional stability
Emotional stability sufficient to assume
responsibility/accountability for actions

Establish therapeutic boundaries

Adapt to changing
environment/stress

Deal with the unexpected (client
going bad, crisis)
Gross motor skills
Fine motor skills
Mobility
Hearing
Visual
Tactile
Auditory ability sufficient for physical
monitoring and assessment of client
health care needs
REQUIRED DOCUMENTATION
The following are required:
 Completed by health care provider
 Provide a photocopy of your immunization/shot record maintained in your physicians office
1.
Measles, Mumps, Rubella (MMR) - Must have two (2) MMR immunizations -- provide photocopy of documentation
OR
 Positive MMR Titer -- provide photocopy of laboratory test
OR
 Birth certificate or drivers license verifying birth prior to 1957 -- provide photocopy of
Birth Certificate or Drivers License
2.
Varicella (Chickenpox)
 Must have two (2) Varicella immunizations -- provide photocopy of documentation
OR
 Positive Varicella Titer -- provide photocopy of laboratory test
3.
Hepatitis B
 Must start the immunizations prior to entering the PARAMEDIC Program
 Document these immunizations on the attached forms for Hepatitis B (If records of
immunization are not available, then may show immunity by having a Hep B Panel drawn.
Results must show Hep. B Ab+ and Hep B Ag Neg.) -- provide photocopy of laboratory
test
4.
TDaP

Must have one immunization within last ten years
 provide photocopy of documentation
5.
Tuberculosis (TB)
 Must have a negative tuberculin skin test not more than three (3) months prior to
entering the PARAMEDIC Program. -- provide photocopy of documentation
if POSITIVE
 Provide current (not more than 3 months prior to entering program) chest x-ray report
PHOTOCOPIES OF ALL DOCUMENTATION REPORTS and LABORATORY
TEST(s) MUST BE ATTACHED
YOUR SUMMARY OF SIGNIFICANT FINDINGS, AND DESCRIPTION OF ABNORMALITIES:
1.
Can applicant perform all of the functional abilities essential for paramedic duties?
2.
Is applicant free of communicable disease?
3.
Is student pregnant? (Pregnant students require a full release to participate in all components
of the Paramedic Program.)
Licensed Health Examiner’s Statement:
I believe the physical and mental health of this applicant will  / will not  enable her/him to
perform the necessary functions of a student paramedic.
___________________________________
____________
Signature
Date
Please Print clearly or type:
Name of Licensed Health Examiner: _____________________________________
Address: ______________________________________________________________________
______________________________________________________________________
Telephone No.: ____________________________