BSNExpress
COLLEGE OF NURSING
VILLANOVA UNIVERSITY
CONFIDENTIAL
800 Lancaster Avenue • Villanova, PA 19085-1699
Phone: (610) 519-4900 • Fax: (610) 519-7650
**COMPLETED FORMS DUE IN THE COLLEGE OF NURSING BY May 19, 2014
Failure to submit a completed Health Record will result in the inability to enter clinical
experiences and to attend classes.
Page one of this form may be completed online by typing onto the lines provided. Once your physician or
NP has completed and signed pages 4 & 5, the form may be delivered, mailed, faxed or emailed to the
College of Nursing. Incomplete records will be returned to student.
CONTACT INFORMATION
Name:
Last
First
Middle
Student ID:
Date of Birth:
College you are entering:
Class of:
Gender:
Entrance Date:
Home Address:
Number and Street
Home Phone:
City
State
Zip
Dorm/Local/Cell Phone:
Email Address: _____________________________________________________
Please list up to three people whom we can contact in case of emergency:
Name
Relationship
Home phone
Work/cell phone
ALLERGIES
Do you have any allergies to the following?
Foods
Latex
Medications
Please specify:
Will you be receiving allergy injections at the Student Health Center?
Yes
No
BSNExpress
Name:
Student ID #:
MEDICAL HISTORY
Indicate below if you have ever experienced any of these problems, please circle “Yes.”
If you are currently experiencing any of these problems, please circle “Currently.”
EYE
URINARY
Corrective Lenses/Contacts
Other Problems
Other
Remarks
Yes
Yes
Currently
Currently
ENT
Kidney Stones
Urinary Tract Infections
Other
Remarks
Yes
Yes
Currently
Currently
Yes
Yes
Currently
Currently
MUSCULOSKELETAL
Ear Problems
Other
Remarks
HEART DISEASE
High Blood Pressure
Palpitations
Heart Murmur
Other
Remarks
RESPIRATORY
Shortness of Breath
Asthma
Bronchitis
Other
Remarks
ABDOMINAL
Irritable Bowel Syndrome
Inflammatory Bowel Disease
Other
Remarks
ENDOCRINE
Diabetes
Thyroid
Yes
Currently
Back Problems
Disease or Injury of Joints
Other
Remarks
Yes
Yes
Yes
Currently
Currently
Currently
HEMATOLOGICAL/ ONCOLOGICAL
Anemia
Yes
Cancer
Yes
Other
Remarks
Yes
Yes
Yes
Currently
Currently
Currently
Yes
Yes
Currently
Currently
Yes
Yes
Currently
Currently
NEUROLOGICAL/PSYCHOLOGICAL
Seizures
Yes
Headaches
Yes
Depression
Yes
Anxiety
Yes
Eating Disorder
Yes
Other
Remarks
GYNECOLOGICAL
Irregular Periods
Severe Cramps
Ovarian Cyst
Other
Remarks
Yes
Yes
Yes
Currently
Currently
Currently
Currently
Currently
Currently
Currently
Currently
Currently
Currently
Other
Remarks
FAMILY HISTORY – Circle all that apply
Mother
Living
Deceased High Blood Pressure
Diabetes
Thyroid Disease
Father
Heart Disease
Cancer
Living
Deceased High Blood Pressure
Diabetes
Thyroid Disease
Other (specify):
Other (specify):
Occupation:
Occupation:
Heart Disease
Cancer
BSNExpress
Name:
Student ID #:
REQUIRED IMMUNIZATIONS –
VACCINE
DATE
LAST BOOSTER
DPT (Diptheria, pertussus, tetanus)
Last date of series
Tdap required
HEP B #1
HEP B #2
HEP B #3
MMR #1
Measles, Mumps and Rubella titer REQUIRED;
please attach results
MMR #2
or
MEASLES #1
MEASLES #2
MUMPS #1
MUMPS #2
RUBELLA #1
.
RUBELLA #2
POLIO VACCINE
(Last date of completed primary series)
MUST HAVE TWO VACCINES
VARICELLA #1
Varicella Titer REQUIRED . Please attach results
VARICELLA #2
or
CHICKEN POX
TUBERCULOSIS SCREENING
– MANTOUX/PPD
(within past 365 days)
REACTIVE
YES
NO (please circle)
______________ mm If PPD+ see note on page 5
CIRCLE:
MENOMUNE OR MENACTRA
Clinician’s initials that information above is correct:
Only necessary if recommended by clinician
BSNExpress
STUDENT HEALTH CENTER
VILLANOVA UNIVERSITY
NON-REQUIRED IMMUNIZATION RECORD
Name:
Student ID:
VACCINE
DATE
BCG – see note below
HEP A #1
HEP A #2
HPV #1 (GARDASIL)
HPV #2 (GARDASIL)
HPV #3 (GARDASIL)
TYPHOID
YELLOW FEVER
OTHER:
If PPD+ as a result of BCG vaccination or prior exposure, student needs to receive QuantiFERON-TB
Gold Test (QFT-G). This is a blood test as opposed to a skin test and is not affected by previous TB
skin tests or BCG vaccination.
BSNExpress
STUDENT HEALTH CENTER
VILLANOVA UNIVERSITY
CLINICIAN’S FORM
CONFIDENTIAL
800 Lancaster Avenue • Villanova, PA 19085-1699
Phone: (610) 519-4070 • Fax: (610) 519-4047
Patient’s Name:
Student ID. #:
TO THE EXAMINING CLINICIAN
Please review the patient’s history, complete the clinician’s form and comment on all positive answers.
BP
CBC*
/
Height
HgB
HcT
Weight
WBC
RBC
Platelets
*complete CBC required
Physical Exam:
Eyes
WNL
Remarks:
Ears
WNL
Remarks:
Nose
WNL
Remarks:
Throat
WNL
Remarks:
Neck
WNL
Remarks:
Lungs
WNL
Remarks:
Heart
WNL
Remarks:
Abdomen
WNL
Remarks:
Lymph glands
WNL
Remarks:
G.U.
WNL
Remarks:
Skin
WNL
Remarks:
Neuro
WNL
Remarks:
Musculoskeletal
WNL
Remarks:
Current Medications: (required)
Is this patient medically qualified to participate in intercollegiate, intramural or club sport activities?
Clinician’s Signature
Date exam was completed
Clinician’s Printed Name
Clinician’s Address
Clinician’s Phone #
Fax #
Yes
No
BSNExpress
Villanova University Health Center
AUTHORIZATION FOR THE RELEASE OF MEDICAL INFORMATION
Pennsylvania state law (specifically 35 p.s. Section 10101) requires any minor who is eighteen (18) years of age or older, or has
graduated from high school, or has married, or has been pregnant, may give effective consent to medical, dental and health services for
himself or herself, and the consent of no other person shall be necessary.
I hereby consent to and authorize the health center to release information about my medical condition to my parents/legal guardian.
Purpose of the Disclosure:
The information may be released in order to keep my parents/legal guardians informed about my general health and medical condition.
I authorize disclosure to my parents/legal guardians of all information contained in my medical records.
My authorization may be revoked at any time.
Signature
Printed Name
Soc. Sec. #
Date
Form revised : 1/24/2013
CON additions: March 1, 2011