Physical Examination Form - Illinois State

Physical Examination Form

Mennonite College of Nursing - Illinois State University

This form is to be completed by a physician or nurse practitioner

__________________________________________ _____________________________________ ______________

Last Name

First Name

MI

____________________ Date of Birth (mo/day/yr)

_____________________ UID

_________________________________________________ Program (Traditional BSN, Accelerated BSN, RN/BSN, MSN, PhD, DNP)

Skin Ears Eyes Nose Throat Mouth/Dental Cardiovascular Respiratory Gastrointestinal Neurological Musculoskeletal Spinal Examination Nutritional Status Other

NORMAL

ABNORMAL

COMMENTS

Height

_ Weight __

Blood Pressure

Ishihara:

__________________________

TDAP date:

__________________________

Pulse

Respiration _ Vision L/R ____ _/_______

Titers Required: IN ADDITION, MUST BE ACCOMPANIED BY EACH TITER LAB REPORT

________________________ Hepatitis B Surface Antibody titer date

___________________________ _________________________

Rubella IgG

Varicella IgG

titer date

titer date

Hepatitis B:

Dates of the 3 injections: #1___________ #2____________ #3____________

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Student Name

UID

Please indicate below if the student has had or is subject to having the following conditions and provide additional information, when available, regarding the course of treatment for the condition(s).

Seizure Disorders Diabetes Asthma Shortness of Breath Allergies/ drug ? food - latex Hay fever, Eczema Cough, Chronic Hoarseness Heart Disease History of Smoking Low/High Blood Pressure Hernia______________________________________________________________________________________ _________ Major Surgery ________________________________________________________________________________________________

What medications are taken on a regular basis?

__________________________________________________________________________________________________

Do you know of any medical condition or physical limitation that would limit the student's ability to engage in clinical nursing behaviors or academic participation? NO YES

Explain____________________________________________________________________________________________

__________________________________________________________________________________________________

_____________________________________________ Print Provider Name and Credentials

____________________________________ Provider Signature (Physician or Nurse Practitioner)

___________ Date

______________________________________________ _____________________________________

Name of Clinic/Provider Address

Provider Telephone Number with Area Code

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