Directions For Completing Medical Requirement Forms (Page 6 of 8) in pdf

Directions For Completing Medical Requirement Forms Page 6

Pre-Entrance Health Examination (To be completed by Physician or NP)

Name: _____________________________________ DOB: __________________ M/F

Ht: __________ Wt: __________ BP: ___________TPR: _____________________

Vision: R_____/20 L ______/20 Corrected Y/N Contacts: Y/N Glasses: Y/N Hearing R: ______ L:______

Systems

Normal Abnormal Findings

Head/Neck

Eyes/Sclera/Pupils

Ears

Nose/Mouth/Throat

Lymph Nodes

Heart: Sounds/Rhythm

Peripheral Vascular

Lungs

Chest Contour

Skin

Abdomen

Reproductive

Hernia

Musculoskeletal: ROM,

posture, spine, strength

Neuro: reflexes,

coordination, balance

Physical Clearance

Nursing students must be able to perform two person lifts/transfers of clients weighing up to 86 kilograms (190

pounds). In your opinion, is this individual capable of performing such lifts/transfers/restraints/or carries safely?

Y/N. If no, please explain: ______________________________________________________________

Person may participate in the following activities:

At the following Level:

Walking _____ Running ____ Lifting ____ Bending _____

Light _____ Moderate _____ Strenuous ___

If a person is NOT CLEARED for participation in any activities, please give reason:

_____________________________________________________________________________________

If there are any other medical conditions of which the college should be aware of (example: epilepsy, diabetes,

allergies, hypertension, pregnancy, MSK injures/physical anomalies etc.) please give recommendations:

__________________________________________________________________________________________

I certify this student _______________ IS/IS NOT physically and mentally fit to undertake the duties of his/her

program.

Office Stamp (name, address, phone #)

____________________________________________________

Signature NP/ DR & Date of Exam

Medical Form

Page 6

Directions For Completing Medical Requirement Forms Page 6