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Bossier Parish Community College
Health Status Statement for the Phlebotomy Program
Name:____________________________________________________________ Date of Exam:_________________
Date of Birth:_________________________ Social Security Number:_____________________________________
Height:___________________________ Weight:__________________________
Allergies:________________________________________________________________________________________
Medications (list over-the-counter and prescribed):__________________________________________________
Vision: Hernia:_____________________ Type:______________
With correction: Right 20/______ Left 20/______ Condition of inguinal rings:_________________________
Without correction: Right 20/______ Left 20/______ Varicocele:________________ Hydrocele:____________
Reaction of pupils:_______________________________
Evidence of disease or injury: Right__________________ Medical conditions that may require attention during
Left __________________ academic attendance, laboratory practice, or clinical
Able to see color and shades of color:________________ rotations: ______________________________________
Able to perceive depth:____________________________ ______________________________________________
______________________________________________
Ears:__________________________________________
Hearing with correction: Right _____ Left _____
Hearing without correction: Right ____ Left _____
Nose & throat:___________________________________
Teeth & gums:___________________________________
Lower extremeties:_______________________________
Varicose Veins:__________ Location:________________
Upper Extremeties:_______________________________
Skin:__________________________________________
Heart:_________________ Hypertrophy:______________
Arrhythmia:___________ Blood pressure S_____/D_____
Murmurs:_____________ Pulse:____________________
Reflexes:
Patellar:______________ Bomberg:________________
Lungs:_________________________________________
Abdomen:______________________________________
Spine:_________________________________________
Apparent Mental Illness:___________________________
Any Evidence of Trauma:__________________________
Deformities:_____________________________________
Will the student be able to meet the following Essential Requirements for the Phlebotomy program?
Walk (varying speeds) for prolonged periods: Yes No Maintain good balance with movement: Yes No
Sit for prolonged periods of time: Yes No Constantly lift items less than 15 lbs: Yes No
Work in a prolonged period of standing: Yes No Occasionally lift items 15 to 20 lbs: Yes No
Frequent twisting of body: Yes No Reach above shoulder level: Yes No
Kneel frequently: Yes No Constantly carry items less than 15 lbs: Yes No
Bend forward frequently: Yes No Occasionally carry items 15 to 20 lbs: Yes No
Pull up to 20 lbs: Yes No Constantly carry items greater than 20 lbs: Yes No
Push up to 20 lbs: Yes No Climb stairs: Yes No
Classify Examinee: Explain Under Remarks, if Classified as II, III, or IV
□ Class I: Physically fit to perform in the Phlebotomy program.
□ Class II: Unfit for performance in the Phlebotomy Program.
Remarks:_______________________________________________________________________________________
Examining Physician’s Signature Examining Physician’s Printed Name
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