Student pages (1-3)
Completed by student & return to OLOLSON: pages (1-2)
Completed by health care provider & return to OLOLSON: pages (3-4)
Our Lady of Lourdes School of Nursing
1600 Haddon Avenue
Camden, N.J. 80103
Student Health Record
Name of Student: _______________________________________________________________________
(Last Name) (First Name) (Middle Name)
Permanent Address: ________________________________________________________________________
(Number & Street)
________________________________________________________________________
(City) (State) (County) (Zip Code)
Phone Number: (______) _________-____________ Cell Number: (______) ________-______________
Email: ___________________________________________________________________________________
Date of Entrance to school: __________________ Sex: ________ Age: _______ Marital Status_________
Place of birth: ______________________________________________ Date of birth: ___________________
(City) (State) (Country) (Month/Day/Year)
In case of illness, notify: ____________________________________________________________________
Relationship ____________________________________Telephone No.:_____________________________
Address: ________________________________________________________________________________
(Number & Street)
_______________________________________________________________________________________
(City) (State) (Zip Code)
PERSONAL HEALTH HISTORY
1. List all allergies including type of reaction experienced:
| |NONE |YES |TYPE OF REACTION |
| | |STATE SPECIFIC ALLERGY | |
|FOOD | | | |
| | | | |
|DRUG | | | |
| | | | |
|LATEX | | | |
| | | | |
|SEASONAL | | | |
| | | | |
|ENVIRONMENTAL | | | |
| | | | |
-2-
|List Medications: |
|Prescribed Medications Used |Name |Dose |Frequency |
| | | | |
| | | | |
|Over the Counter Medications | | | |
|Herbal Preparations | | | |
|Homeopathic Remedies | | | |
2. Medical History: List any acute or chronic health conditions:_____________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
3. List any physical disabilities or limitations:
Describe:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________
4. List any learning disabilities, disorders or limitations:
Describe:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________
5. List any visual or auditory disabilities or impairments:
Describe:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
-3-
PHYSICAL EXAMINATION
Name & Address of Healthcare Provider:_____________________________________________________
________________________________________________________________________________________
|Name: | PHYSICAL STATUS | | PHYSICAL STATUS |
|Exam Date: | | | |
|General | |Noses and Sinuses | |
|Height /Weight | |Septal Deviation | |
|Pulse | |Sinus Tenderness | |
|Respiration | |Inflammation | |
|Blood Pressure | |Smell | |
|Face | |Mouth | |
|Symmetry | |Lips | |
|Texture | |Buccal Mucosa | |
|Lesions | |Gums and Teeth | |
|Eruptions | |Palate | |
|Hair Distribution | |Tongue | |
|Involuntary Movements | |Pharynx | |
|Head | |Throat | |
|Proportion to Body | |Tonsils | |
|Scalp Condition | |Neck | |
|Eyes | R | L |Nodes | |
|Vision (Snellen) | | |Trachea | |
|Corrected | | |Thyroid | |
|Visual Fields | | |Thorax | |
|Lacrimal System | | |Shapes, Size, Symmetry | |
|Conjunctiva | | |Breasts | R | L |
|Cornea and Lens | | |Size and Symmetry | | |
|Pupils | | |Masses or Nodules | | |
|Retina | | |Discharge from Nipples | | |
|Ears | | |Lungs | |
|Hearing | | |Resonance | |
|Canal | | |Breath Sounds | |
|Tympanic Membrane | | |Diaphragmatic Movement | |
|Heart | |Genitalia: (Only If Indicated) | |
|Rate and Rhythm | |Male: Penis | |
|Heart Sounds | | Scrotum | |
|Murmurs and Thrills | | Hernias | |
|Abdomen | | Prostate | |
|Appearance/Scars | |Female: External Genitalia | |
| | |(Only If Indicated) | |
|Bowel Sounds | | Vagina | |
|Tenderness | | Cervix | |
|Masses | | Uterus | |
|Palpable Organs | | Rectovaginal Exam | |
|Peripheral Vascular | |Anus and Rectum | |
| | |(Only If Indicated) | |
|Pulses | |Neurological | |
|Edema | |Reflexes | |
|Veins | |Motor System | |
|Musculoskeletal | |Sensory System | |
|Gait | |Mental Status | |
|Posture | | | |
|Joints & Range of Motion | | | |
-4-
|Attach copy of results of required lab studies: |IMMUNIZATION RECORD |
|TITERS REQUIRED FOR: |Tetanus: (Date last received):___________ |
|Measles Mumps, Rubella (MMR) | |
|Varicella | |
|Hepatitis B (if series completed) | |
|BOOSTERS required for non-immune status: |Hepatitis B Series: Date Received: |
|Measles Mumps, Rubella (MMR) |1st dose: _______________________ |
|Varicella |2nd dose: _______________________ |
|Hepatitis B (if series completed) |3rd dose:_______________________ |
|CBC: |Two Step PPD (1 month prior to entrance) |
|Urinalysis: |1st Dose: Date Given: ________________ |
|Comprehensive Metabolic Panel: |Date Read: Results: _________________ |
| | |
|Chest X-Ray: |2nd Dose: Date Given:________________ |
|(only if PPD is positive or prior history of BCG) |Date Read: Results: _________________ |
Summary, Remarks and Recommendations:
*Please indicate if student is medically cleared to engage in full nursing activities without limitations.
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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Health Care Provider’s Signature/Credentials: ____________________________________________
Date of Exam: _________________
**STAMP OF HEALTH CARE PROVIDER’S OFFICE LOCATION:
9/2012 - BMS
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