CERTIFIED NURSE AIDE
STUDENT HEALTH RECORD
PART I - to be completed by Student
Name _____________________________________________________________ Date ________________________
Street __________________________________________________________________________________________
City ___________________________________________________ State ____________________ Zip____________
Home Phone ____________________________ Cell __________________________________
Date of Birth ____________________________
Male Female 
PART II- to be completed by Health Care Provider
Physical Assessment:
Height _____________
Weight ____________
Date Completed _______________________
BP ____________ P __________ T ___________ R ________
Allergies ________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Medications _____________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Pertinent Past Medical/Surgical History (include impairments and work restrictions) ____________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Head/ENT _______________________________________________________________________________________
Cardiac _________________________________________________________________________________________
Lungs __________________________________________________________________________________________
GI _____________________________________________________________________________________________
Musculo/Skeletal _________________________________________________________________________________
Genito/Urinary ___________________________________________________________________________________
Skin ____________________________________________________________________________________________
Comments _______________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
EW 4/13/2010
Continued on reverse
Student Name______________________________________________
PART II- to be completed by Health Care Provider (cont’d)
Immunization Verification Certificate
A. Purified Protein Derivative (PPD) Please provide documentation of a Mantoux skin test for tuberculosis within the previous
twelve (12) months, including the date done and size of reaction. For those with a previous positive reaction, documentation
attesting to the fact that the individual is not infectious along with any prophylaxis used and the date and size of reaction must be
provided by a physician.
Performed within the previous 12 months (A tine test is not acceptable.) ............................................... (Date) ________________
Result __________________________________________________________________________________________________
If Mantoux is positive, report of current chest X-ray (within 12 months) ..................................................... (Date) ________________
Result __________________________________________________________________________________________________
B. Rubella (German Measles) Patient has had at least one dose of rubella vaccine, given on or after the first birthday, or serological
evidence (blood test) of immunity to rubella, regardless of the age or job status of the person.
1st Dose: (Date) _______________________ __________
2nd Dose: (Date) _____________________________________
or
Immune Titer: (Date) ______________________________ A copy of the lab results for titer tests must be included.
C. Rubeola (Measles) Attach written evidence of two doses of live measles vaccine or serological evidence
(blood test) of immunity. One dose should have been given on or after the first birthday, and at least one
dose should have been given after 1968. The two doses should be separated by at least 30 days.
1st Dose: (Date) _______________________ __________
2nd Dose: (Date) _____________________________________
or
Immune Titer: (Date) ______________________________ A copy of the lab results for titer tests must be included.
D. Varicella Zoster (Chickenpox) Patient has had clear history of having had chickenpox .......................... (Date) ________________
or Vaccine Administered ............................................................................................................................ (Date) ________________
or
Immune Titer: (Date) ______________________________ A copy of the lab results for titer tests must be included.
E. Hepatitis B Patient has completed a vaccination series or has signed a declination statement.
1st Dose ..................................................................................................................................................... (Date) ________________
2nd Dose .................................................................................................................................................... (Date) ________________
3rd Dose ..................................................................................................................................................... (Date) ________________
Declination statement (please attach) .................................................................................................................
F. Tetanus Booster within past ten (10) years recommended not required.
Received tetan
(Date)
G. Influenza vaccine (flu shot) within current flu season:
The above-named individual has been examined by this office and found to be free of any communicable diseases and
physically able to participate in lifting, moving and bathing patients in the Certified Nurse Aide Program at Manchester
Community College. NOTE: Immune Titer – A copy of the lab results for titer tests must be included.
Name of Physician/Clinic _______________________________________________________________________________________
Address ___________________________________________________ City _______________ State ___________ Zip ___________
Phone ___________________________________________________ Fax ______________________________________________
Signature of Physician _____________________________________________________ Date ____________________
EW, 4/13/2010 p2