WEA home Wicks

 

Please print this form and have it completed by a licensed health care practitioner.

Name: _______________________________________  Date: ___________________________

  1. Height: Weight: Posture: BP:
  2. Eyes: Vision R/20 corrected by glasses to 20/
                        L/20 corrected by glasses to 20/
               Color Perception External exam
               Papillary reaction
  3. Ears: Hearing (low conversational voice) R/20 L/20
          Inspection including tympanum: R L
  4. Nose and Throat
  5. Mouth and Teeth Caries Missing Teeth
  6. Cardiovascular: Heart Sounds: Pulse
         Varicosities?
  7. Chest: X-Ray (result)
         or TBC Skin Test (result)
         Auscultation and Inspection
  8. Abdomen Hernias
  9. Rectum and Genitalia (optional)
  10. Glandular System: Lymph Thyroid Mammary
  11. Bones, Joints & Muscles:
  12. Nervous system (including tendon reflexes and gross coordination:
  13. Skin
  14. Lab Urinalysis: Albumin Sugar
        Micro (if indicated)
         HCT Rubella Titer
    Rubeola Titer or imm. Date Hepatitis B Vaccine
  15. Limitation or restriction on physical activity, diet, etc?  Why?

IMMUNIZATIONS:       TB/PPD Results __________     Date _____________

  Rubella Vaccination/Titer ________   Date _________     Rubeola Vaccination/Titer ___________    Date __________

  Varicella Vaccination/Titer _______   Date _________    Hepatitis B Comp Date ________________

  Mumps Vaccination/Titer ______________                      CPR Expiration Date  __________________

  Other tests:  (i.e., Drug testing) may be required prior to placement in a clinical setting.

Licensed Health Care Practitioner_________________________________________

Address: ___________________________________________________________

Phone ______________________________ DO, MD, NP, PA-C (circle one)

 

 

Signature ________________________________ Date _____________________



 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WICKS EDUCATIONAL ASSOCIATES, INC.

                                                               

WOC NURSING EDUCATION PROGRAM

 

 

HEALTH FORM (  to be filled out by the student)

 

 

Please print clearly or type.

 

NAME

 

 

 

 

ADDRESS

 

 

 

CITY

STATE

ZIP

DATE OF BIRTH

 

 

 

SEX

 

NEXT OF KIN

 

 

 

PHONE #

HEALTH INSURANCE COMPANY

ADDRESS

POLICY OR CONTRACT #

 

 

EXPIRATION DATE OF POLICY

 

 

 

HEALTH INSURANCE IS REQUIRED FOR ACCEPTANCE INTO THE PROGRAM.   INCLUDE A PHOTOCOPY OF YOUR INSURANCE CARD WITH THIS FORM.

 

 

HAVE YOU HAD SURGERY?                                 YES  _______________                 NO  _______________

                                                                              

IF YES, PLEASE LIST:

 

 

 

 

 

 

 

 

DO YOU TAKE MEDICATION, PILLS, OR USE OTHER DRUGS REGULARY?

 

                                                                                    YES  _______________                 NO  ________________

IF YES, PLEASE LIST:

 

 

 

 

 

 

 

INFORMATION PROVIDED IS CONFIDENTIAL AND FOR USE BY WEA, INC. ONLY.

 

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© 2004 All Rights Reserved
Wicks Educational Associates, Inc., Maple Building, Suite 202, 5012 Lenker Street, Mechanicsburg, PA 17055; Phone: 1.800.807.WICKS or 717.737.2770; Fax: 717.737.7683; E-Mail: wicks@epix.net

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