Appendix B

CUMBERLAND UNIVERSITYJeanette Cantrell Rudy Division of NursingStudent / Instructor Health Form________________________________________________________________Last Name First MI

Home Address____________________________________________________________________Street City State Zip Code

_____________ __________________ ___ _____________ _________ ________ Date of Birth Social Security No. Sex Marital Status Home Phone Work Phone

________________________________________________________________________Name of Health Insurance Company & Group/Policy Number(s)

____________________________________________________________ ___________ Name of Parents, Guardian, or Spouse (Address & Phone if Different From Above Phone________________________________________________________________________IMMUNIZATIONS/TITERS REQUIRED

HEALTH CAREHEPATITIS B VACCINE DATE Provider's Initial

Dose # 1 _____ __________ Dose # 2 (to be given 1 month after the 1st injection) ______ ____________Dose # 3 (to be given 6 months after the 1st injection) ______ ____________

TETANUS (within the last 10 years) ______ ____________

**MUMPS TITER (attach copy of lab report)**RUBEOLA (Red Measles) TITER (attach copy of lab report)**RUBELLA (German Measles) TITER (attach copy of lab report)**VARICELLA TITER (attach copy of lab report)***HEPATITIS B TITER (attach copy of lab report)

**This titer must include IGG antibody levels.

***This must be a QUANTITATIVE TITER and is to be drawn 30-60 days after the third injection._______________________________________________________________________________________PAST MEDICAL/SURGICAL HISTORYHave you had surgery? List surgery dates. _____________________________________________________________ ______________________________________________________________________________________Have you been treated for any serious illness? Give details_________________________________________________Are you presently on any medication? If so, list medication(s).______________________________________________Have you been treated for any psychological/emotional problems? Give details. ________________________________Is there a family history of a bleeding disorder, cancer, hypertension or diabetes? List and state relationship. _______________________________________________________________________________________________Do you have any current health problems/limitations that will affect your ability to function as a nursing student? Give details __________________________________________________________________________________________________________________________________________________________________________________________

CHILDHOOD DISEASESHave you ever had: MUMPS: Yes No CHICKEN POX: Yes No SCARLET FEVER: Yes NoMEASLES: Yes No DIPTHERIA: Yes No GERMAN MEASLES: Yes NoNOTE TO HEALTH CARE PROVIDER: Health examination form may be completed by a physician, nurse practitioner or a licensed physician’s assistant.

PHYSICAL EXAMINATIONAge________ Height________ Weight________ Blood Pressure________

Normal Abnormal Comments Eyes _____ _____ _________________________________Ears _____ _____ _________________________________Nose and Throat _____ _____ _________________________________Sinuses _____ _____ _________________________________Mouth and Teeth _____ _____ _________________________________Chest _____ _____ _________________________________Heart _____ _____ _________________________________Abdominal Viscera _____ _____ _________________________________Endocrine Viscera _____ _____ _________________________________Nervous System _____ _____ _________________________________Lymphatic Glands _____ _____ _________________________________Orthopedic Defects _____ _____ _________________________________

LABORATORY TESTINGURINALYSIS: Protein________ Sugar________ Blood________

CBC (attach lab report): Date________

TB SKIN TEST #1 Date__________ TB SKIN TEST RESULT: ________ Date Read: ___________ TB SKIN TEST #2 Date __________ TB SKIN TEST RESULT ________ Date Read: ___________

CHEST X-RAY (if positive skin test): Date________ Results_____________________

Examiner’s Signature___________________________ Date_______________________

ADDITIONAL INFORMATION

In case of serious illness or accident, I give Cumberland University or its representative(s) permission to secure medical and/or surgical care to include transportation to a doctor or hospital of their choice, injections, examinations, medication, and surgery that is considered necessary for my good health. I agree to pay all medical costs.

Signature of Student _____________________________ Date_____________________Parent or Guardian (if under age 18)_______________________ Date________________

Please note your admission process is not complete until completed form is received.