Cape GirardeauCareer & TechnologyCenter
Cape Girardeau, Missouri
IMMUNIZATION, HEALTH HISTORY RECORD
AND PHYSICAL FORM FOR CAN STUDENTS
IMMUNIZATION/HEALTH HISTORY
Name______Sex______Birth date______
Address______
Family Doctor______
Address______
All students/instructors from the Cape Girardeau CTC using the medical facilities for teaching/learning purposes as outlined in the contracts are required to comply with the Student/Instructor Health Histories Policies and immunization or disease shall be supplied upon request. Any immunizations, titres, x-rays that are required, shall be at the expense of the student named on this form.
The following information must be completed as directed before the student may use the above institutions for learning purposes.
NOTE: In general, live virus vaccines are contraindicated in pregnant females.
I. DT, POLIO AND INFLUENZA
Diphtheria-Tetanus immunizationYES____NO____
(Date of the immunization must be within past ten years.)
Initial series of 3 polio Booster (Sabine, Trivalent) YES____NO____
Received Polio BoosterYES____NO____
Trivalent Influenza VaccineYES____NO____
(Influenza Vaccine is suggested but not required.)
- TUBERCULIN SKIN TESTING
Date of PPD Skin Test ______
(Must be within past 6 months and repeated on year from date.)
Finding of Skin Test______
Chest x-ray report for individuals with history of positive TB skin test is REQUIRED.
Date of PPD Skin on year from above date______
Finding of Skin Test______
IMPORTANT NOTE:
We will need proof for the Doctor’s Office of you TB test (the date and the results). This information needs to be put on the Physical Exam (this is to be filled out by a physican).
III. NOTE: If you have received immunization for measles/mumps and *Rubella. If no documentation is available, individual must obtain immunizations before working. The County Nursing Service supplies this vaccine free of charge with a physicians order. Persons vaccinated for measles between 1957 and 1967 will need to be revaccinated unless documentation (physicians statement, history of measles, or laboratory evidence of immunity) is presented.
*Counseling for women by a physician is required prior to receiving the Rubella vaccine.
Measles immunizationYES_____ NO_____
History of measles YES_____NO_____
Laboratory evidence of immunity if no immunization or physicians statement my be requested.
*Rubella immunizationYES_____ NO_____
History of RubellaYES_____ NO______
(No immunization, had disease)
Laboratory evidence of immunity if no immunization or physicians statement may be requested.
IV. An accurate history of chickenpox is needed. If the individual has not had chickenpox by history and the titre is negative, the student/instructor must be aware of the policy that is to be followed if exposed to chickenpox. (see-4.) Varicella (chickenpox) under XII. Herpes Viruses in the School’s copy of the Health Policies of Southeast MO Hospital.
History of chickenpox (had disease)Yes ______NO______
If you have not had chickenpox or you are not sure if you have had the disease, You must have a chickenpox titre done and attach results here:
V. History of Hepatitis B Carrier State, or Non-A or Non B Hepatitis, Tuderculosis, Herpes (including fever blisters) or Acquired Immune Deficiency (AIDS)
History of Hepatitis B CarrierStateYes____NO____
History of Non-A HepatitisYes____NO____
History of Non-B HepatitisYes____NO____
History of TuberculosisYes____NO____
History of Herpes Simplex IYes____NO____
History of Herpes Simplex II (Genital Herpes)Yes____NO____
History of Herpetic Whitlow (Hand Lesions)Yes____NO____
History of Herpes Zoster (Shingles)Yes____NO____
History of Acquired ImmuneYes____NO____
Deficiency SyndromeYes____NO____
Describe any current medical problems:
______
Have you had any previous work related injuries:Yes____NO____
If yes, then describe them below. Include a description of any permanent disability that remains as a result of the injury.
______
Describe any physical limitations that have been given to you by a physician.
______
Describe any back problems that affect your ability to lift or bend.
______
Has your health in general been: Excellent Good Fair Poor
Medications:
NameHow TakenReason Prescribed
______
Allergies and Adverse Reactions:
NameType of Reaction
______
My signature indicates that all of the above information as requested is to the best of my knowledge, an accurate and complete description of my personal health history and immunizations.
______
Signature of Student Date
PHYSICAL EXAM
(To be done by a physician)
Temperature ______Height ______
Weight ______
Systolic BP ______
Diastolic BP ______
Pulse ______
Respiration ______
Complete the physical examination. “/” indicates the system examined was normal. “X” indicates the system examined was abnormal. Describe abnormal findings.
Results of recent Tuberculin Skin Test:
Type of test given: ______
mm of induration at 48 hrs. ______
mm of induration at 72 hrs. ______
Results of Chest X-ray if appropriate: ______
General ( ) ______
Skin ( ) ______
Head ( ) ______
Eyes ( ) ______
Ears ( ) ______
Nose ( ) ______
Mouth ( ) ______
Neck ( ) ______
Breast ( ) ______
Lymph Node ( ) ______
Heart ( ) ______
Lungs ( ) ______
Chest Wall ( ) ______
Back and Spine ( ) ______
Abdomen ( ) ______
Extremities ( ) ______
Neurological ( ) ______
DIAGNOSIS :
- ______
- ______
- ______
- ______
- ______
- ______
- ______
- ______
- ______
- ______
How would you describe the applicant’s overall health? Excellent Good Fair Poor
Do you feel the applicant is physically able to work in a nursing home? Yes No
Is the applicant free from contagious disease? Yes No
What possible problems do you foresee that would affect the applicant’s ability to work in a nursing home during the next year?
______
______
______
______
______
______
______
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Physician Signature ______
Date ______/______/______