SONOMA STATE UNIVERSITY

Department of Nursing Health Evaluation Form

Student Name: ______Date: ______Last First

Birthdate: ______Gender: Male Female

Address: ______Street City State Zip Code

Phone Number: ( )______

In case of emergency, notify: ______( ) ______

Name Phone

PERSONAL HEALTH HISTORY

(Comment below if "YES" to any question) Yes No

1. Have you ever been rejected for service or employment

for medical reasons: ______

2. Have you ever had epilepsy (seizures)? ______

3. Have you ever been addicted to drugs or alcohol? ______

4. Do you have diabetes? ______

5. Have you ever had professional counseling for mental health problems? ______

6. Are you taking medications regularly? ______

7. Have you ever had asthma? ______

8. Have you ever had tuberculosis? ______

9. Have you had back trouble or back injuries? ______

10. Have you ever had any other significant medical problems not listed? ______

11. Do you have any special needs that will need to be accommodated

in the nursing program? ______

Comments (Explain any "YES" answers by number)

GENERAL APPEARANCE Normal Abnormal / GENERAL APPEARANCE Normal Abnormal
Head/Eyes/Nose/Throat / Pelvic (optional)
Lymph Nodes / Neurological
Breasts/Chest / Neck
Heart
/ Upper Extremities
Lungs / Lower Extremities
Abdomen / Back
Genitalia / Reflexes

Please explain any abnormal history or findings:

PHYSICAL EXAMINATION

Blood pressure: ______/______

Pulse: ______Height (without shoes) ______ft. ______in.

Weight (in ordinary clothes) ______lbs. Color Vision: P F

Distance: OD 20/ _____ OS 20/______Corrected: OD 20/_____ OS 20/______

Near vision: OD 20/ _____ OS 20/______Corrected: OD 20/_____ OS 20/______

SUMMARY

List any medications taken regularly:

List allergies to food, medicine or other:

What recommendations have you made to this student?


IMMUNIZATION HISTORY

MMR: #1 ______Titer levels: ______/ ______

Date Measles Rubella

#2 ______Second Measles shot necessary if born after 1957

Date (1st measles shot must have been given after the age of 12 months and the second must have been given at least 4-6 weeks after the first)

Influenza/Declination (complete form) ______Date

H1N1 ------

Date

Tdap: ______(Most recent)

Date

Varicella # 1 ______Titer Levels ______

Date

# 2 ______

Date

HEPATITIS B: Series dates: #1 ____/____/____

#2 ____/____/____

#3 ____/____/____

OR

HBsAB Titer Date: _____ / _____/ _____

TB TEST: On the initial tuberculosis skin test (TST), if a student does not have a documented

negative TST within the previous 12 months a two-step TST needs to be obtained.

Test One:

RESULTS: ____ Positive _____ Negative DATE READ: ______

Test Two (if required)

RESULTS: ____ Positive _____ Negative DATE READ: ______

If positive, student must be cleared by the Health Care Provider in writing, following fulfillment of provider’s recommendation and CDC regulations

If student has had a positive result in the past and follow-up chest Xray, provider must document student is free of active signs of tuberculosis.

______

Signature, Health Care Provider Date

______

Printed Name Telephone #

______

Patient Name:

SSU Dept of Nursing page 4