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:(_____ ) ______