Health Status Assessment printable pdf download

Health Status Assessment

College of Health Sciences

Biomedical Sciences Department

HEALTH STATUS ASSESSMENT

NAME _______________________________

STUDENT # ___________________

TO PHYSICIAN:

This UWM student is required to have a complete health status

assessment before starting their clinical laboratory training.

Please indicate the dates the following tests were completed:

Immunizations: see attached form for guidelines

Physical Examination

_____________

History

_____________

Hepatitis B:

#1 ____________

Height/Weight/ BP

_____________

#2 ____________

Vision Screen &

#3 ____________

Test for Color Blindness

_____________

MMR: #1____________ #2_____________

TB Skin Test or Chest X-ray

_____________

(Measles, Mumps, Rubella)

or Blood Assay (QFT, TSPOT)

(within 3 months prior to starting clinical training)

Tetanus-diptheria-pertussis (Tdap):___________

______________

Drug Screen

Varicella (Chicken Pox): ___________________

(Please attach a copy of the report to this form)

Influenza vaccine: _______________________

Examiner's Signature ___________________________________

Date______________

Print Name: ___________________________________

______

Address

: ___________________________________________

City, State, Zip: _____________________________________

Telephone:

______________________________________ E-mail: __________________________

Return completed form to:

Cindy Brown, Undergraduate Programs Director

UW-Milwaukee

College of Health Sciences

BioMedical Sciences Department

Enderis Hall – Room 467

P.O. Box 413

Milwaukee, WI 53201

Fax: 414/229-6227

Phone: 414/229-5299

E-mail:

cbrown@uwm.edu

Health Status Assessment

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