Student Health
Forms
Accelerated Nursing Program
Important: This packet includes a comprehensive set of
forms required by NYS Health law. These forms are
required in order to register for classes. Please review each
form carefully and follow the instructions for each section.
Some sections will require completion by your Health Care
Provider.
If you have any questions, please contact the Student Health
Services office at 914.337.9300, x2243.
STUDENTS MAY NOT ATTEND CLASSES UNTIL ALL HEALTH FORMS ARE
COMPLETED AND APPROVED BY CONCORDIA HEALTH SERVICES
Students: Once your health care provider has completed this form, make a copy
for your records and return the original to the address listed on this sheet. Forms
may also be faxed to (914) 395-4521. This form is not valid if any information is
missing and will not be processed without a health care provider’s signature,
stamp, and license number.
Health Care Providers: Complete all parts of Section I- B. For each section, place a
check beside the relevant documentation being provided and provide the date of
immunization, illness and/or serologic testing, in the corresponding space to the
right. Please note the date format of Month/Day/Year (MM/DD/YY). This form
will not be processed without a health care provider’s signature, stamp, and license
number. Lab reports MUST accompany titer results.
Section I-A and I-B
MANDATORY
History, Health Requirements & Physical
Examination/Blood Titers Form
This section covers mandatory health requirements in order to be cleared for
nursing clinical rotations.
A physical examination by a clinician should be performed within the last year.
Section II.
MANDATORY
Meningococcal Vaccine READ CAREFULLY. As per
New York State Public Health Law 2167, you must either have the vaccine or
sign a waiver stating you have read about the disease and decline the vaccine.
If you have questions regarding the Health Services Center or to schedule an
appointment please call (914) 337-9300, x2243
Please return
completed forms in
`
the enclosed
envelope to:
Concordia College-New York
Student Health Services
171 White Plains
RoadBronxville, NY 10708
or
SEC I-A: Personal Health History (To be completed by Student)
Name: _________________________________________
(LAST NAME, FIRST IN BLOCK LETTERS)
This is a confidential record. Information you provide will be used solely as an aid to providing health care while you are a student.
Student Type
: Accelerated Nursing Program: ____Housing Status:
Resident____ Commuter____Personal Information:
Age: _______ Gender: Male____ Female____ Date of Birth_______________Marital Status: Single____ Married____ Widowed____ Divorced____
Name: _____________________________________________________________ Social Security #: _______________________ Last First Middle Maiden Name
Home Address: _____________________________________________________ Telephone: ____________________________ Street City State Zip
Are you currently insured? Yes No Provider/Carrier/Company: ________________________________________________________ Address of Provider: ___________________________________________________ Telephone: ____________________________
Street City State Zip
Name on Insurance Policy: _______________________________________________ Policy #:______________________________
Insured Date of Birth: _____________ Name of Employer that provides insurance (if applicable):______________________________ (Please attach a copy of the insurance card, front and back)
Have you attended Concordia College before? Yes No If yes, From ______________ To________________ Circle: College Year 1 2 3 4 5 Have you attended another college? Yes No If yes, From _____________ To _______________ Person to be notified in emergency: Name:_______________________________ Relationship:_____________________________
Address:_____________________________________________________________________________________________________
Telephone: Home: ________________________ Work:_________________________
Personal History:
Please answer all questions. Comment on all positive answers in space allowed (see next page).
Have you had: Yes No Yes No
Scarlet Fever Thyroid Disease
Measles
German Measles Surgery:
Mumps Appendectomy
Chicken Tonsillectomy
Malaria Hernia Repair
Nose/Throat Trouble Other Eye Trouble
Recurrent Colds Allergies to:
Sinusitis Penicillin
Hay Fever Sulfonamides
Serum
Joint Disease or Injury: Foods (list below)
"Trick" Knee, Shoulder Other Back Problems
Diarrhea/Constipation Females Only:
Gallbladder/Gallstones Irregular Periods Rupture, Hernia Severe Cramps Jaundice (Liver Disease) Excessive Flow
Name: ___________________________________________________________________________
Yes No Yes No
Frequent Anxiety Chronic Cough Frequent Depression Shortness of Breath Nervousness Heart Murmur Head injury Heart Palpitations with Unconsciousness Rheumatic Fever Recurrent Headache Pain/Pressure in Chest Gum/Tooth Problems Blood Pressure
Acne High or Low Epileptic Seizures Diabetes Tumor, Cancer, Cyst Frequent Urination Dizziness, Fainting Sexually Transmitted Weakness/Paralysis Disease (STD)
Tuberculosis Recent Weight Gain
Asthma or Loss
A. Has your physical activity been restricted during the past five years? Yes No (If yes, explain below.) B. Have you received treatment or counseling for a nervous condition, personality or character disorder, or emotional problem? Yes No (If yes, give details below.)
C. Have you had any illness or injury or been hospitalized other than already noted? Yes No (If yes, give details below.) D. Have you consulted or been treated by clinics, physicians, or other practitioners within the past five years?
(other than routine checkups?) Yes No E. Do you smoke, dip, or chew tobacco? Yes No
F. Do you take any medication at present? Yes No (If Yes, Please list below)
G. Do you drink alcohol? Yes No If Yes, what type and how often?______________________________________ H. Do you use recreational drugs? Yes No (If Yes, Please list below)
Comments:
___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________________________________________________________
Family History
Among your relatives is there any history or present illness from the following: If yes, what relative?
Yes No Relative Yes No Relative Cancer ____________ Convulsions ____________ Diabetes Arthritis ____________ Allergy Stomach disease Tuberculosis Nervous difficulties ____________ Kidney Disease ____________ Any other disease ____________ Heart disease, ____________
high blood pressure, or stroke
Medical and Surgical Authorization
In case of illness and/or injury, authority and consent is given to Concordia College for examination and treatment of named student either at the Health Center, Concordia College, or by outside physicians and medical facilities as are available. Consent is further given for admission to a hospital for necessary medical or surgical treatments as ordered by a physician. It is agreed that all medical and/or hospital expenses incurred beyond those covered by any applicable student insurance policy will be paid directly and promptly by the undersigned student and parents or guardians and the College will not be held responsible.
Date ____________ Student's Signature ____________________________________________________________ Age __________
Date ____________ Parent or Guardian's Signature _________________________________________________________________
Sec. I-B.
PHYSICAL EXAMINATION AND BLOOD TITERS (To be completed by a Health Care Provider)Student’s Name: _______________________________ Concordia ID#: C_____________
Gender (circle): M F Date of Birth: ________________
Date of Exam: ________________
(to be completed only by MD, DO, NP or PA)Height: ___________ Weight:____________ BMI:________ BP:____________ Pulse:__________
Vision: R 20/ L 20/ Corrective Lenses? Y N
Current Medications: ______________________________________________________
Allergies to Medications: ___________________________________________________
Type of reaction: ____________
Other Allergies: __________________________________________________________
Type of reaction: ____________
SYSTEM NORMAL DESCRIBE ABNORMALITY
Skin
HEENT
Lungs/Chest
Breasts
Heart/Vascular System
Abdomen (rectal if
indicated)
Genito-urinary
Pelvic (if indicated)
Musculoskeletal
Neurological
Psychological
Other:
Current & Chronic Problems
1.______________________________ 2._______________________________
3. ___________________________
IF THE STUDENT IS UNDER CARE FOR A CHRONIC OR SERIOUS ILLNESS, PLEASE DESCRIBE BELOW AND ATTACH ADDITIONAL CLINICAL REPORTS TO ASSIST US IN PROVIDING
CONTINUITY OF CARE.
_____________________________________________________________________________________________ _____________________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
RECOMMENDATIONS FOR PHYSICAL ACTIVITY:
Unlimited
Limited
(specify):________________
________________________________________________________________________
Tuberculin Skin Test (PPD only)
To have been done within six (6) months prior to coming to Concordia
Date Planted: ___________________________________
Date Read: _____________________________________
Results in mm: __________________________________
o If chest x-ray was done, please attach a copy of report
o If treatment was administered after a positive result, please attach records
o If QuantiFERON - TB Gold Assay was done, please attach lab result
_________________________________________________________________________
Health Care Provider (please print) ________________ License #_______________
Address: ____________________________________________________________
Phone :(________)________________________
Fax :(_________)_________________________
Provider’s Signature/Stamp: ___________________________________________
PLEASE SEE NEXT PAGE CONTAINING LIST OF
MANDATORY TITERS AND VACCINES TO BEGIN
NURSING PROGRAM!
MANDATORY NURSING IMMUNIZATION REQUIREMENTS
ATTENTION HEALTH CARE PROVIDERS!!
PLEASE DO NOT VARY FROM THIS CHECKLIST! DOING SO WILL PREVENT YOUR PATIENT
FROM OBTAINING HEALTH CLEARANCE FOR CLINICAL PRACTICE
!!!
Annual Physical within the last 12 months
Proof of immunity
via blood titers
for:
o Measles
o Mumps
o Rubella
NOTE
: Non-immunity to
measles
requires 2 MMR vaccines
Non-immunity to
mumps
or
rubella
requires 1 MMR vaccine – There is no need to re-titer.
o Varicella
NOTE: Non- immunity to
varicella
will require 2 Varicella vaccines
o Hepatitis B surface Antigen
o Hepatitis B surface Antibody
o Hepatitis C (antibody)
NOTE :
*If Hepatitis B surface antibody is negative, proof of having begun the 3-vaccine series for
Hepatitis B will be required
OR
Signature on the OSHA Hepatitis Declination Form
Vaccinations:
Hepatitis A : two-vaccine series
Proof of having had a Tdap* Vaccine within the last 10 years
Vaccine MUST be Tdap which contains the pertussis requirement – Td will NOT be acceptable
Signed Meningitis waiver [SEC II] (found in this packet) OR
Dates received the Meningitis vaccine
PPD (Mantoux) or QuantiFERON TB Gold blood test – results obtained within 6 months of
beginning clinical rotations- Provide documentation of chest x-ray if testing and treatment if
provided if tested positive in the past. If tested positive in the past, complete TB questionnaire
ONLY COMPLETE IF TESTING POSTIVE FOR TB IN THE PAST!!!
TUBERCULOSIS SCREENING QUESTIONNAIRE
Name: __________________________________________________Date:_________________________
Positive TB skin test (PPD) Date: ____________________
Last Chest X-Ray Date: ___________________________
Please indicate if you are having any of the following problems for three to four weeks
or longer:
Chronic Cough (greater than 3 weeks) Yes _____ No _____
Production of Sputum Yes _____ No _____ Blood-Streaked Sputum Yes _____ No_____
Unexplained Weight Loss Yes _____ No_____ Fever Yes ______ No _____
Fatigue/Tiredness Yes _____ No _____ Night Sweats Yes _____ No _____
Shortness of Breath Yes _____ No _____
NO EVIDENCE OF PULMONARY TUBERCULOSIS OR CONTAGIUM
Signature: _
__________________________ DATE:
____________________________Sec. II. Meningococcal Meningitis Vaccination Response Form
(To be completed by Health Care Provider)
A.
Meningococcal Meningitis Vaccine (Menactra™/Menomune™): Please consider this vaccine.
Students wishing to decline this vaccine must read the information in the box below. Signing the
waiver indicates that you understand the possible risk involved in not receiving this
immunization. If you are under the age of 18, a parent or legal guardian must sign this waiver for you.
Mandatory - Read Carefully
: As per New York State Public Health Law 2167, you must either
have the vaccine or sign a waiver stating you have read about the disease and decline the
vaccine.
(circle one:) Menomune / Menactra
A. Meningococcal Meningitis Vaccine (Menactra, Menomune, Menveo) given within the
past 10 years:
B. Date: ____/______/______
Month Day Year
