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

PHYSICAL EXAMINATION

NAME: ________________________________________ DATE: __________________

HEIGHT: __________ WEIGHT: __________ POSTURE: __________ BP __________

EYES: Vision R/20 Corrected by glasses to 20/__________

L/20 Corrected by glasses to 20/__________

Color perception: __________ External Exam: __________

Pupillary reaction: __________

EARS: Hearing (low conversational voice) R __________/20 L __________/20

Inspection including tympanum: R __________ L __________

NOSE & THROAT: ________________________________________________________________

MOUTH & TEETH: _________________ Caries __________ Missing Teeth ___________

CARDIOVASCULAR: Heart Sounds _______________ Pulse _____________

Varicosities _______________

CHEST: Auscultation and Inspection ________________

ABDOMEN: __________ HERNIAS: __________ RECTUM & GENITALIA: __________

(Optional)

GLANDULAR SYSTEM: Lymph __________ Thyroid __________ Mammary __________

BONES, JOINTS & MUSCLES: ___________________________________________

NERVOUS SYSTEM ________________________________________________________________________

(Including tendon reflexes and gross coordination)

SKIN ____________________________________________________________________

LAB URINALYSIS: Albumin __________ Sugar __________ Micro (if indicated) _________

LIMITATION OR RESTRICTION ON PHYSICAL ACTIVITY, DIET, ETC. & WHY:

__________________________________________________________________________________________________________________________

LICENSED HEALTH CARE PRACTITIONER: __________________________________________________

Address: _________________________________________________________________________________________

Phone #: ______________________________________________ DO, MD, NP, PA-C (Circle One)

RELEASE:

I give permission for this form to be sent to the clinical preceptor/agency selected for my clinical instruction.

Signature: _______________________________________________ Date: _____________________________

IMMUNIZATION RECORD

Name ______________________________________________ Date ____________________________

Most healthcare agencies require current immunization information prior to a student’s placement in their clinical agency/facility. The following information is most frequently requested. Individual affiliates may request more current information..

1. Significant Medical History (Current medical status including impairments or restrictions, allergies,

drug sensitivities)

2. Current TB Skin Test (Mantoux) within 12 months

Date: ____________________ Result (Induration in mm): ________________

If Mantoux is positive, report of current chest x-ray (within 12 months)

Date of Chest x-ray ________________________ Result ___________________________________

3. Mumps Titer

Date: ___________________ Result ________________ Interpretation: _____ positive _____ negative

OR Date of Mumps Vaccination: #1 __________________________ #2 ______________________________

4. Rubeola (Measles) Titer

Date: ___________________ Result ________________ Interpretation: _____ positive _____ negative

OR Date of Measles Vaccinations: #1 __________________________ #2 ______________________________

NOTE: Two doses of measles vaccine are recommended for people entering medical facilities. Vaccinations given before 12 months of age are not acceptable. Measles vaccine prior to 1968 is only acceptable if live vaccine was used.

5. Rubella (German Measles) Titer

Date: ___________________ Result ________________ Interpretation: _____ positive _____ negative

OR Date of Rubella Vaccination: #1 __________________________ #2 ______________________________

6. Varicella (Chicken Pox) Titer

Date: ___________________ Result ________________ Interpretation: _____ positive _____ negative

OR Date of Varicella Vaccination: #1 __________________________ #2 ______________________________

7. Hepatitis B: Comp Date: ____________________________________________

8. CPR Expiration Date: ___________ (Copy of Certificate required)

Signature of Health Care Provider:

Signature ___________________________________________________ Date Completed: ___________________

Name (Printed) ______________________________________________________________________________________

File: healthform2009

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.

� 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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