STUDENT HEALTH FORM
AD-NURSING PROGRAM
College of Menominee Nation
P. O. Box 1179
Keshena, WI 54135
715-799-5600
Health History & Physical Examination
_________________________________________________________________________________________________________________
Last Name
First Name
MI
Former Name (If applicable)
______________________________________________________________________________ Date of birth ______/________/________
Permanent address
City
State
ZIP
Month
Day
Year
______________________________________________________________________________ __________________________
Mailing Address (if different)
City
State
ZIP
County
__________________________________________________________________________________________________________________
Telephone # (Home)
(Work)
(e-mail)
Emergency Contact
Telephone # (Home)
(Work)
(Must be completed by a licensed Health Care Provider.)
Is there any significant medical history or condition that could affect functioning as a nursing student,
including interaction with patients and staff in clinical settings? **
NO
YES
If yes, please explain:__________________________________________________________________
Is this individual currently taking any medication that could affect participation in a nursing education
program, including interaction with patients and staff in clinical settings? **
NO
YES
If yes, please explain:__________________________________________________________________
I, (Print Name) , ______________________________certify that the above named student has been
examined by me on (Date):_______ /_______ /_______ and is found to be in good physical and mental
health and appears able to undertake all aspects of the nursing education program, including interaction with
patients and staff in clinical settings. **
Practitioner’s signature:___________________________________________________________________
License number:___________________________ State/Country Licensed:__________________________
Licensed as (check one):
�ARNP
�Physician Assistant
** Please see reverse: “Essential Functions for Clinical Course Work”
�Physician
College of Menominee Nation Associate Degree Nursing Program
Essential Functions for Clinical Coursework
Students expecting to enroll in clinical courses in the Associate Degree Nursing Program must be
able to fully perform the essential functions in each of the following categories: decision making,
manual dexterity, communicative, monitoring, motor ability, and sensation. It is recognized that
degrees of ability vary widely among individuals. The Associate Degree Nursing Program is open to
consider candidates with any form of disability utilizing case by case analysis. Individuals are
encouraged to discuss disabilities with the Disability Services Counselor for accommodations. The
College of Menominee Nation Associate Degree Nursing is committed to providing reasonable
accommodations to students with disabilities upon notice and through established policies and
procedures.
 Ability to make decision based upon:
Depth perception (3
dimensional)
Visual acuity
Color perception
 Manual Dexterity (wrists, hands,
fingers, arms):
Grasping
Pulling
Pushing
Carrying
Twisting (rotating)
Pinching
Cutting
 Ability
to Monitor:
Body sounds
Mechanical devices
 Motor
Abilities:
To position another person
To support another person
To provide motion exercise
To transfer to/ambulate with
walker, cane, crutches, bed,
chair
To perform CPR;
resuscitation

 Sensation:
Communication Abilities:
Assertiveness
Sensitiveness
Effectively consulting and
negotiating as par of a team
Delegating
Attending
Hearing
Touch, palpation
Temperature
Students in the health professions are held to standards of conduct that may exceed those typically
expected of college students. Adherence to the standards of acceptable conduct as outlined in the
American Nurses Association Code of Ethics and the Wisconsin Nurse Practice Act is required.
MANDATORY IMMUNIZATIONS FORM
AD-NURSING PROGRAM
College of Menominee Nation
P. O. Box 1179
Keshena, WI 54135
715-799-5600
_________________________________________________________________________________________________________________
Last Name
First Name
MI
Former Name (If applicable)
______________________________________________________________________________ Date of birth ______/________/________
Permanent address
City
State
ZIP
Month
Day
Year
Required Immunizations (please provide the moth, date and year for every dose administered.
Immunization
Mo
Day
Yr
Mo
Day
Yr
Mo
Day
Yr
Mo
Day
Yr
Mo
Day
Yr
DPT (Diphtheria, Pertusis and
Tetanus)
Td or TD
(Diphtheira and Tetanus)
Tdap
(Tetanus Diphtheria Pertussis)
Combined MMR
(Measles/Mumps/Rubella)
Combined MR
(Measles and Rubella)
Polio
(Specify IPV/OPV)
Titer Date: (copy of titre must be attached)
Hepatitis B (HB)
DIAGNOSIS OF DISEASE IS NOT ACCEPTABLE
Titer Date: (copy of titre must be attached)
Disease Date OR
Titer Date: (copy of titre must be attached)
DIAGNOSIS OF DISEASE IS NOT ACCEPTABLE
Titer Date: (copy of titre must be attached)
Disease Date OR
Titer Date: (copy of titre must be attached)
Varicella
Rubeola (Red Measles)
Live Virus Vaccine
Rubella (3 day or German
Measles)
Mumps
Tuberculosis Skin Test (PPD by Mantoux within the past year)
Two-step PPD
PPD #1
Date
Placed
Date
Read
Month
Day
Result
Month
Year
Day
Year
(record
in mm)
Neg
Pos
Neg
Pos
_____
PPD #2
Date
Placed
Date
Read
Month
Day
Result
Month
Year
If positive PPD,
Date of chest x-ray
Day
Year
(record
in mm)
_____
MUST SEND COPY
OF CHEST X-RAY REPORT!
Month
Day
Year
Health Provider Signature (Physician, Health Professional verifying that immunizations were given)
________________________________________________________________________________________________
SIGNATURE
****See reverse side…..
DATE
College of Menominee Nation Associate Degree Nursing Program
Mandatory Immunizations
_________________________________________________________________________________________________________________
Read Carefully
A health care provider must sign all information. We recommend that you keep a copy for your own records and followup with the
Nursing Office to make sure we receive your records. You will not be allowed to register for AD-Nursing classes unless you
provide proof of immunity.
Exemptions: It is the student’s responsibility to contact the Nursing office to apply for any of the following
exemptions,
 Students born prior to 01/01/1957,
 Medical or Religious exemptions.
Proof of immunity:
 Attach or submit this immunization form or card signed by a medical physician, such as a high school physical
form. OR
 Have a medical physician complete and sign this form. OR
 Submit copies of medical documentation of vaccine information, illnesses or antibody test results.
What is Required:
To be in compliance with the mandatory immunization requirements, students must provide documentation of numbers 1-7
which follow. Information submitted will be compiled on the Mandatory Immunization and Student Health Form which will be
located in the student’s file in the Nursing Office.
1. Measles
• Born before December 31, 1956; or,
• Laboratory evidence of immunity; or,
• Immunization with two doses of measles vaccine after the first
birthday with at least 30 days between doses.
2. Mumps
• Born before December 31, 1956; or,
• Health care provider-diagnosed mumps; or,
• Laboratory evidence of immunity; or,
• Immunization with 2 doses of mumps vaccine on or
after the first birthday.
3. Rubella
• Laboratory evidence of immunity; or,
• Immunization with 2 doses of Rubella vaccine on or after the first
birthday.
4. Tetanus and Diphtheria/(Td) or Tetanus/Diphtheria/Pertussis (Tdap)
• Record of booster every 10 years
5. Hepatitis B (HBV)
• A series of three doses of vaccine is required ; or,
• Evidence of Hepatitis B vaccination series in process, with completion of
series by the start of the second semester of study in the AD-Nursing; or,
• Laboratory evidence of Hepatitis B immunity.
6. Tuberculosis
• Initial two-step negative PPD then an annual PPD skin test with negative reactivity; or,
chest x-ray and medical follow-up for those with past history of positive reactivity.
7. Varicella
• Born before December 31,1956; or,
• Health care provider-diagnosed history of disease; or,
• Completed vaccinations with a series of two doses; or,
• Laboratory evidence of immunity.