Health Physical Examination Form - Southwest Wisconsin Technical
ADVERTISEMENT
1
2Mail or fax completed form to:
Virginia Reynolds – College Health Records Office
Southwest Tech – Health Science Center
1800 Bronson Boulevard, Fennimore, WI 53809
Phone:
608-822-2648
FAX:
608-822-2776
Email:
vreynolds@swtc.edu
HEALTH/PHYSICAL EXAMINATION FORM
STUDENT’S NAME: ____________________________ SEX: ______ BIRTH DATE: ___________________
STREET: _______________________________ CITY: ____________________ STATE: ___ ZIP: __________
PHONE: (
) _________________ E-MAIL: ___________________________________________________
SOCIAL SECURITY NUMBER: _____________________ DATE STARTING PROGRAM: ___________________
If previously enrolled at SWTC, program attended: ________________________________
Year _______
PROGRAM:
ADN (Full-Time)
EMT/AEMT
Nursing Assistant
ADN (Part-Time)
Health Information Mngt
Paramedic Technician
Cancer Information Mngt
Medical Assistant
Physical Therapist Asst
Child Care/Early Childhood
Medical Lab Tech
Dental Assistant
Midwife
Date of Physical Exam must be no more than 2 years prior to the beginning the clinical experience. Form is to be turned into the College Health
Records Office. NO student will be permitted to start clinical until this form and the TB Skin Testing Form have been submitted and approved.
PHYSICAL FINDINGS
(To be completed by an MD/CNP or PA)
Height: __________ Weight: ___________
B/P: ___________ P _______ R ________
Basic Vision Screening: ___________________________________
Do abnormalities appear in the following systems?
Ears, eyes, nose, throat
Yes
No
Musculoskeletal
Yes
No
Gastrointestinal
Yes
No
Genitourinary
Yes
No
Cardiovascular
Yes
No
Metabolic
Yes
No
Respiratory
Yes
No
Neurological
Yes
No
If yes, please specify/explain: _______________________________________________________
________________________________________________________________________________
This individual is free from communicable diseases within the parameters of this assessment.
Yes
No
Special recommendations regarding the health or physical limitations of this student while participating
in the program named at the top of this form:
For Child Care Program Students: I certify, based upon my examination that this person appears to be
physically able to work with children. NOTE: This individual will be in contact with children receiving child care
services and may be responsible for the physical care and social development of young children during the
hours child care is provided. Some lifting of young children may be required.
Physician’s Signature: __________________________________________________________
Print name: __________________________________________________________________
Street: ______________________________________________________________________
City: _________________________________________ State: _______ Zip ____________
Telephone: ______________________________________
Date: _____________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Education