University of Scranton Department of Nursing

Annual Health Evaluation

Sophomore Students/Fall 2013

The information requested is required by the State Board of Nursing of the Commonwealth of Pennsylvania and/or by the clinical agencies the student will be assigned to for his/her nursing clinical rotations.

Return all information by August 1st to: Debbie Zielinski, RN, MS

Department of Nursing

University of Scranton

Scranton, PA 18510

Name (Last, First, Middle)

______Date of Birth: ______

BP: Height Weight: ______

Allergies:______

The following blood work must be completed and the results handed in with your completed physical exam form.

Rubella IGG titer level(MUSTattach a copy of the titer level, required by hospital clinical sites)

Immune Not immune_ _(Re-immunize if not immune)

Varicella IGG titer level(MUSTAttach a copy of titer level even if client has a history of chickenpox or received the varicella vaccine.)

Immune __ Not immune ____ (Immunize, if not immune)

Hepatitis B surface antibody level(MUST Attach a copy of titer level) Immune Not immune ___

Results can also be faxed to 570-941-7903.

PPD and physical exam must have been completed after April 30, 2013.

Two Step PPD (Mantoux) (Tine or monovac not acceptable). Attach copy of PPD tests:

First Test # of mm Date Completed: ______CXR needed if PPD positive_____

2nd Test** # of mm Date Completed ______Submit copy of CXR if one needed

**Apply second PPD 2 weeks after, and no sooner, the application of the first PPD.

Physical Examination:NormalAbnormalDescribe Abnormalities

Head, Ears, Nose, or Throat______

Eyes______

Respiratory______

Cardiovascular______

Gastrointestinal______

Genitourinary______

Musculoskeletal______

Metabolic / Endocrine______

Neuropsychiatric______

Breast______

General Comments:

Recommendations for physical activity: Unlimited / Limited

Explain: ______(turn page)

Is the patient now under treatment for any medical or emotional condition? Yes / No

If yes, please explain. ______

______

Immunization Record:Month/Year

Tetanus-Diphtheria

( ) Completed Primary series of 4 doses with DtaP, DTP, DT or Td. (Date completed)...... ____/___

( ) Received tetanus-diphtheria (Td) booster within the last 10 years...... ____/___

Due to the increase of number of documented cases of pertussis in the United States and pertussis related infant deaths all nursing students must have documented that he/she has received a dose of the Tdap vaccine.

( ) Tdap (Adacel or Boostrix) one dose is REQUIRED, DOCUMENT DATE RECEIVED. ____/___

.

M.M.R. (Measles, Mumps, Rubella)

( )Dose 1 - Immunized at 12 months or after and before 5 years...... _____/_____

( )Dose 2 - Immunized at 5 years or later or at least 28 days after first dose...... _____/_____

Rubella - if given instead of MMR...... _____/_____

Note*Local hospitals require an immune titer report despite immunization history-please attach.

If student is not immune to rubella he/she must be immunized. Dose 1 / Dose 2 ____/____

Measles (Rubeola) - if given instead of MMR.

( )1st Dose - Immunized with live measles vaccine at 12 months after birth or later...... ____/_____

( )2nd Dose - Immunized at 5 years or later...... ____/_____

( )Had report of a positive immune titer. Specify date of titer...... ____/_____

( )Had disease; confirmed by office record...... ____/_____

( )Born before 1957 and therefore considered immune...... Yes___/No___

Mumps - if given instead of MMR.

( )Had disease; confirmed by office record...... … ____/____

( ) Report of a positive immune titer attached...... Yes___/No___

( )Immunized with vaccine at 12 months after birth or later...... ____/_____

( ) Born before 1957 and therefore considered immune...... Yes___/No___

Polio......

( )Complete primary series of polio immunization. Yes / No (circle one.) Check type of vaccine.

Type of vaccine: OPV (Sabin, 3 doses), IPV (Salk-4 doses), IPV/OPV sequential

Date of last booster...... ____/_____

Varicella : All students must have a varicella titer level, if student is not immune, he/she must be immunized.

Varicella titer: Positive Negative

( ) Immunized with vaccine...... Dose #1 _____/_____

( ) Second dose should be 4 to 8 weeks after first dose ...... Dose #2 /_____

Hepatitis B

( )Immunization...... Dose #1 _____/_____

...... Dose #2 _____/_____

...... Dose #3 _____/_____

*A hepatitis B surface antibody titer level is required. Attach results. Reactive Non-reactive______

Health Care Provider's Signature: Date:

Name (please print):______

Address:______

______

Telephone:(_____ ) ______