University of Scranton Department of Nursing
Annual Health Evaluation
Sophomore Students/Fall 2013
The information requested is required by the State Board of Nursing of the Commonwealth of Pennsylvania and/or by
the clinical agencies the student will be assigned to for his/her nursing clinical rotations.
Return all information by August 1st to:
Debbie Zielinski, RN, MS
Department of Nursing
University of Scranton
Scranton, PA 18510
Name (Last, First, Middle)
_________________________________________________________________ Date of Birth: _______________
BP:
Height
Weight: _________
Allergies:_____________________________________________________________________________________
The following blood work MUST be completed and the results handed in with
your completed physical exam form.
Rubella IGG titer level (MUST ATTACH A COPY OF THE TITER LEVEL, REQUIRED BY HOSPITAL CLINICAL SITES)
Immune
Not immune_
_(Re-immunize if not immune)
Varicella IGG titer level (MUST ATTACH A COPY OF TITER LEVEL EVEN IF CLIENT HAS A HISTORY OF
CHICKENPOX OR RECEIVED THE VARICELLA VACCINE.)
Immune
__ Not immune ____ (Immunize, if not immune)
Hepatitis B surface antibody level (MUST ATTACH A COPY OF TITER LEVEL) Immune
Not immune ___
Results can also be faxed to 570-941-7903.
PPD and physical exam must have been completed after April 30, 2013.
Two Step PPD (Mantoux) (Tine or monovac not acceptable). Attach copy of PPD tests:
First Test # of mm
Date Completed: __________CXR needed if PPD positive_____
2nd Test** # of mm
Date Completed __________ Submit copy of CXR if one needed
**Apply second PPD 2 weeks after, and no sooner, the application of the first PPD.
Physical Examination:
Head, Ears, Nose, or Throat
Normal
_____
Abnormal
_____
Describe Abnormalities
_____________________________________
Eyes
_____
_____
_____________________________________
Respiratory
_____
_____
_____________________________________
Cardiovascular
_____
_____
_____________________________________
Gastrointestinal
_____
_____
_____________________________________
Genitourinary
_____
_____
_____________________________________
Musculoskeletal
_____
_____
_____________________________________
Metabolic / Endocrine
_____
_____
_____________________________________
Neuropsychiatric
_____
_____
_____________________________________
Breast
_____
_____
_____________________________________
General Comments:
Recommendations for physical activity: Unlimited / Limited
Explain: ____________________________________________________________________________ (turn page)
Is the patient now under treatment for any medical or emotional condition? Yes / No
If yes, please explain.
____________________________________________________________________________________________
_____________________________________________________________________________________________
Immunization Record:
Month/Year
Tetanus-Diphtheria
( ) Completed Primary series of 4 doses with DtaP, DTP, DT or Td. (Date completed). . . . . . . . . . . . .____/___
( ) Received tetanus-diphtheria (Td) booster within the last 10 years.. . . . . . . . . . . . . . . . . . . . . . . . . . ____/___
Due to the increase of number of documented cases of pertussis in the United States and pertussis related infant
deaths all nursing students must have documented that he/she has received a dose of the Tdap vaccine.
( ) Tdap (Adacel or Boostrix) one dose is REQUIRED, DOCUMENT DATE RECEIVED.
____/ ___
.
M.M.R. (Measles, Mumps, Rubella)
()
Dose 1 - Immunized at 12 months or after and before 5 years. ............................................ _____/_____
()
Dose 2 - Immunized at 5 years or later or at least 28 days after first dose ........................... _____/_____
Rubella - if given instead of MMR....................................................................................................... _____/_____
Note*Local hospitals require an immune titer report despite immunization history-please attach.
If student is not immune to rubella he/she must be immunized.
Dose 1
/
Dose 2 ____/____
Measles (Rubeola) - if given instead of MMR.
()
1st Dose - Immunized with live measles vaccine at 12 months after birth or later. ............... . ____/_____
()
2nd Dose - Immunized at 5 years or later. ............................................................................ . ____/_____
()
Had report of a positive immune titer. Specify date of titer.. . . . . . . . . . . . . . . . . . . . . . . . . . ____/_____
()
Had disease; confirmed by office record. .............................................................................. ____/_____
()
Born before 1957 and therefore considered immune. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Yes___/No___
Mumps - if given instead of MMR.
()
Had disease; confirmed by office record. .............................................................................. … ____/____
()
Report of a positive immune titer attached. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Yes___/No___
()
Immunized with vaccine at 12 months after birth or later. ..................................................... .. .____/_____
()
Born before 1957 and therefore considered immune. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes___/No___
Polio
()
..............................................................................................................................................
Complete primary series of polio immunization. Yes / No (circle one.) Check type of vaccine.
Type of vaccine:
OPV (Sabin, 3 doses),
IPV (Salk-4 doses),
IPV/OPV sequential
Date of last booster ............................................................................................................... . ____/_____
Varicella : All students must have a varicella titer level, if student is not immune, he/she must be immunized.
Varicella titer:
Positive
Negative
()
Immunized with vaccine. . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . Dose #1 _____/_____
()
Second dose should be 4 to 8 weeks after first dose . . . . . . . . . Dose #2
/_____
Hepatitis B
()
Immunization. . . . . .. . . . . .. . . . . . .. . . . . . . . .. . . . . . . . . . . . . . . Dose #1 _____/_____
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dose #2 _____/_____
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . .Dose #3 _____/_____
*A hepatitis B surface antibody titer level is required. Attach results. Reactive
Health Care Provider's Signature:
Name (please print):
Address:
Telephone:
Date:
_____________________________________
_____________________________________
_____________________________________
(_____ ) ______________________________
Non-reactive ______