Gadsden State Community College

Gadsden State Community College

Initial Health Appraisal Form

Health History Report

Information may not be released to a third party unless a proper acceptable authorization is furnished. This release must comply with State and Federal Regulations. Incomplete or inaccurate information may delay your clearance, cancel your

registration or cause improper decision of your future medical care.

General Information

Name:______________________________________________________ Social Security # _____/___/_______

Last

First

Middle

Date of Birth:________/________/________ Age:____________

Gender (circle) M F

International Student: Yes No

If Yes, what country?: __________________________________________

Entering Semester: Spring Summer Fall Year ___________

Student Number (G#)___________________________________________________

e-mail Address:_________________________________________________________

Permanent Address: _________________________________________________________________________

Street or P.O. Box

City

State

zip

Local Address :

____________________________________________________________________________________

Street or P.O. Box

City

State

zip

Telephone Number: (____) _______________ Cell: (____) _______________ Work (____)_______________

Emergency Contact-Name_____________________________ Relationship_______________ Phone#_____________

Authorization: All statements in this form are true to my knowledge. I understand that this form is a part of my official application to the Health Science Program. I agree to notify the Dean of Health Science of any change that occurs either prior to my registration or while I am a student at GSCC.

_____________________________________________________________________________________________

Date

Signature of Applicant

_________________________________________________________________________________________________________

Date

Signature of Parent or Guardian if student is under 19 years of age

TO BE COMPLETED BY STUDENT

Medical History

1. Do you smoke? Yes No If so, how much and for how many years? ________________________________________

2. Do you drink alcoholic beverages? Yes No If so, type and number of drinks per week: _________________________

3. Are you concerned about your utilization of alcohol or drugs? Yes No

4. Are you allergic to any medications, foods, environmental agents? Yes No

5. List any medications you currently take. Include over-the-counter and prescription medications. _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________

6. List any surgeries or procedures you have had and give the date for each.

_________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________

7. Do you have any restrictions on your physical activities?

Yes No

If Yes, explain:____________________________________________________________________________________________________

8. Are you under treatment for any medical or emotional condition? Yes No If Yes, explain:_____________________________________________________________________________________________________

Have you ever had or do you currently have: (Please check to the right of each item that applies, indicate year of first occurrence)

Hypertension Heart Problems Asthma/Wheezing Tuberculosis Chronic Cough Cancer Alcohol/Drug Problem Seizures Frequent Headaches Diabetes Chickenpox Mononucleosis

High Blood Pressure Stroke Cancer Heart Attack Cholesterol Diabetes

Yes No

Year

Back, Bone or Joint Problems Depression Bipolar Disorder Anxiety/Panic Attacks LD/AD/ADHD Hepatitis Eating Disorder Sickle Cell Anemia Blood Disorders Thyroid problems Eye or Hearing Problems Other

Yes No

Year

Family History Has any person related by blood had any of the following?

Yes No

Relationship

Glaucoma Blood or Clotting Disorder Alcohol Problems Psychiatric Suicide Drug Problems

Yes No

Relationship

TO BE COMPLETED BY EXAMINER Physical Examination

Height:________ Weight __________lbs.

Date LMP:_________________________

Temp________ Pulse ________ RR _________ B/P____________ Re-Check B/P (Manual)______________

Visual Acuity Testing

Distance

Corrected Uncorrected

Right 20/________Left 20/______ OU________ Contact Lenses: Yes No Right 20/________Left 20/______ OU________

Glasses: Yes No

Near

Corrected Uncorrected

Right 20/________Left 20/______ OU________ Color Vision ____________________________ Right 20/________Left 20/______ OU________

Peripheral Vision: Right Temporal 85? 70? Left Temporal 85? 70?

55? Right Nasal: 45? 55? Left Nasal: 45?

Ears: Is hearing normal? Yes No

Head, Nose & Throat Respiratory Cardiovascular Gastrointestinal Genitourinary Hernia Musculoskeletal Neuropsychiatric Skin Metabolic/Endocrine Organ loss or impairment

PLEASE EXAMINE AND COMMENT ON THE FOLLOWING SYSTEMS:

Normal Abnormal

Remarks or additional information

Review of past Medical History, Surgical History and Medications Additional Comments: __________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

Are there any existing or past abnormalities or conditions that might affect the student's health adversely during the nursing affiliation? No ________ Yes________ If yes, please explain ________________________________________________________________ __________________________________________________________________________________________________________ Are there any existing or past abnormalities or conditions that might affect the student's ability to function in a health care agency? No ________ Yes________ If yes, please explain ________________________________________________________________ __________________________________________________________________________________________________________

The student was examined on _____________ and was found to be physically, mentally and emotionally healthy and is released to participate in all student activities, including activities requiring patient interaction in the medical setting. Additional comments/concerns:

The student was examined on _____________ and requires clearance related to _______________________ from treating physician.

Clearance Received Date: ___________________

The student was examined on _____________ and was not found to be physically, mentally and emotionally healthy and/or is not released to participate in all student activities, including activities requiring patient interaction in the medical setting. Additional comments/concerns:

___________________________________________________________

Print name of Physician/Physician Assistant/Nurse Practitioner

____________________________________________________________

Signature of Physician/Physician Assistant/Nurse Practitioner

Date

________________________________

Office address/phone number

____________________________________________________________

Signature of student

Date

INDIVIDUAL IMMUNIZATION REPORT

Student Name __________________________________________________________

Program of Study________________________________________________________

2 Step TB skin Test Must be given within 6 weeks prior to arrival

to GSCC PPD #1

Placement Date (MM/DD/YY)

PPD #2

Annual PPD

Referral to County Health Department

Yes No

Date Read (48-72 hours) (MM/DD/YY)

PPD>5mm Yes No

Result in mm

CXR needed for positive test or

allergy

TB high risk protocol recommended Yes No

Treatment Initiated Refused

CXR result

Treatment Completed Yes No

Disease Hepatitis B Hep B booster series Hepatitis A/B combo

Vaccine

Vaccine

(MM/DD/YY) (MM/DD/YY)

Vaccine (MM/DD/YY)

Titer Test Date HBsAb

Result

Immune

Not

Non Converter

Immune

Disease

Measles (Rubeola) 2 Doses required

Rubella (German Measles) 1 dose required Mumps 2 doses Required OR Combines as MMR 2 doses required

Primary Vaccine (MM/DD/YY)

Booster Vaccine (MM/DD/YY)

Results Date

Rubeola lgG

Rubella lgG

Mumps lgG

Immune

Not

Immune

Post Series Titer Date

Post Vaccination Titer Results/Date Immunity Status

Disease

Tdap: If Td booster has not been received in the last two years.

Td Vaccine Tdap Vaccine (MM/DD/YY) (MM/DD/YY)

Exemption and Explanation

Disease Varicella 2 doses

Vaccine

Vaccine

(MM/DD/YY) (MM/DD/YY)

Titer Date

Result VZV IgG

Immune Not

Post Vaccination Titer

Immune Results/Date Immunity Status

Disease Influenza

Vaccine (MM/DD/YY)

Vaccine (MM/DD/YY)

Exemption and Explanation

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