Fillable Nursing Program Health Record (Dallas County Community College)

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Nursing Program Health Record (Dallas County Community College)

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Nursing Program Health Record
Date: ________________ Student Name: ____________________Last: _____________First: ____________Middle: ___________
ID#___________________________ DOB: _______________________________ Email: _________________________________
Address Street: ____________________________ City: _____________________ State: ________________ Zip: ______________
Telephone: Home: _______________________ Work: ____________________________ Cell: ____________________________
Health Questionnaire: To be filled out by applicant.
I certify that I h
ave:
1. Visual acuity, with or without corrective lenses. This includes but is not limited to the ability to complete a patient
assessment, read small print, visualize and interpret monitors, and equipment calibrations. Yes
___ No____ if no, explain:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
2. Hearing ability with or without auditory aids to understand the normal speaking voice without viewing the speaker’s face.
This includes but is not limited to hearing monitor alarms, emergency signals, patient call bells, and stethoscope sounds
originating from the patient’s blood vessels, heart, lungs, and abdomen. Yes
___ No____ If no, explain:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
3. Physical ability to
stand for prolonged periods of time and a reasonable level of strength and endurance. This includes but is
not limited to the ability to lift a minimum of 50 pounds, perform cardiopulmonary resuscitation, lift patients, move from
room to room, maneuver in small spaces, and complete twelve hour shifts. Yes___ No____ If no, explain:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Ability to communicate effectively orally, aurally, and in writing. This includes but is not limited to the ability to speak
clearly and understandably to members of the health care team, patients, and families. The student must possess the ability to
write legibly and professionally and use effective listening skills. Yes
___ No____ If no, explain:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
4. Manual dexterity,
strength, and fine motor skills. This includes but is not limited to the ability to utilize sterile technique,
prepare and administer medications, turn and move patients, and perform other nursing procedures/skills. Yes
___ No____ If
no explain,
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
5. Reliable personal transportation and ability to attend all classroom and clinical experiences, both on and off campus. Yes___
No____ If no, explain:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
6. A normal level
of health and immunity. This includes but is not limited to the ability to tolerate immunizations and to work
with a wide variety of potentially contagious patients. Yes
_____No____ If no, explain:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
7. Ability to function safely and professionally under various stressful conditions.
Yes
___ No____ If no, explain:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
8. Eligibility to
meet Texas Board of Nursing Licensure Requirements. This includes but is not limited to passing a criminal
background check and drug and alcohol screening. (Please be aware that some criminal history or psychiatric illnesses may
preclude an individual from licensure eligibility.) Yes
___ No____ If no, explain:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Please answer the following questions:
1. Are you currently pregnant? If yes, do you have any limitations that would prevent you from being able to complete any of
the tasks listed in the previous questions? Yes
___ No____ If yes, explain:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
2. Do you have any othe
r conditions which might interfere with your ability to practice nursing? Yes
____ No___ If yes,
explain:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
3. List any presc
ription, over-the counter, or other medications or substances you have been using on a regular or frequent
basis during the past year (You may continue on a separate sheet of paper. Make sure your name and ID number are at the
top of the page).
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Immunization Requirements
The Texas Department of Health follows the Centers for Disease Control (CDC) guidelines for immunizations for Health Care
Workers. Dallas Fort Worth Hospital Council may require additional immunizations for participation in healthcare institutions for this
area. Students entering the nursing program must be able to demonstrate evidence of immunity through documentation of
disease/vaccination records and titer reports indicating immunity (positive titer). No student will be allowed to attend any clinical
without evidence of immunizations. Below is a list of all required immunizations. All immunizations and titers must be completed
prior to making application to the MVC nursing program effective 9/1/2019
• Each immunization requires a copy of the original record including the signature of the health professional who
administered the immunizations and presentation of copies of all available immunization records.
• A positive titer will be accepted for unavailable immunization documentation. This applies only to titers that are
indicated in the required column.
• Vaccines are not required if you have documentation of the disease and positive titers.
• List all dates of immunizations/disease and titers below.
Vaccine Information Date Given
(mm/dd/yy)
Date of Positive titer
Required
Hepatitis B
(HepB, Hib-HepA, HepA-
Hepb, DT
ap-HepB-IPV)
2 doses 4 weeks apart, third dose 5 months after
the second dose and positive titer.
1.
2.
3.
Hepatitis B:
Meningococcal
(MCV4, MPSV4)
All stud
ents under the age of 22 attending classes
at Texas institutions of higher education must
present proof of immunization of bacterial
meningitis or present the appropriate exemption
1. ________
N/A
Tdap
Booster (one dose as adult) within the last 10
years. Td Booster every 10 years thereafter.
1. ________
N/A
Measles, Mumps, & Rubella
(MMR, MMRV)
Documentation of 2 doses with a positive titer
1.
2.
Measles:
Mumps:
Rubella:
Varicella (chickenpox)
(VAR, MMRV)
2 doses are required. (If one dose was received
prior to age 13, then only 1 dose is required) and
positive titer.
1.
2.
Varicella: ________
I
nfluenza Required annually during flu season usually from
September through March or April.
1. ________
N/A
TB Test
Negative Tuberculin (TB) test (can be either TST
or QFT). If history of positive TST or having had
TB, must have documentation of negative CXR.
1. ________
N/A
If a Chest X-ray was done
for Tuberculosis Screening please submit documentation of testing with a physician’s or nurse’s signature
or verification from the Health Facility. Update will be required annually while enrolled in Dallas College Mountain View program.
Chest x-ray- within one (1) year if PPD positive
Date
________ Results ___________________________________________________
Provider S
ignature_
________________________________________________________
________
________
________
________
________
________
________
________
________
__
__
____
________
Physical Examination
To be completed by physician, nurse practitioner or physician assistant.
Date: ____________ Name: Last __________________ First_________________ Middle __________________ Sex__________
Height ________ Weight ________ TPR__________ BP _________ Hearing________
Vision ______________ Glasses ____________ Contact Lens : R ______ L ______
History: (Attach separate sheet if needed) Include any significant information regarding pertinent medical and surgical conditions
and use of alcohol and/or drugs. Physical exam form will not be accepted without health provider signature or verification
General Appearance
Check each item in appropriate column
Normal Abnormal Describe every abnormality in detail
(attach sheet if necessary)
Eyes-ears-nose-throat
Mouth, teeth, neck
Heart and Vascular
Lungs
Abdomen and Viscera
Back, Vertebrae
Extremities
Skin
Neurologic
Attach appropriate lab data to this health record document
I believe this applicant is physically, mentally and emotionally healthy enough to participate in a nursing education program. I am
aware that this program includes care of patients who are hospitalized. I also believe that the student has the ability to lift or carry
objects that weight up to 50 pounds.
Health Care Provider Printed Name:
_______________________________ Signature: _______________________________
Date of exam: ____________________________ Address of Provider: ___________________________________________
Physical
exam form will not be accepted without either the provider signature stamp or on attached letterhead from the provider
confirming the validity of the information indicated on the physical examination from.
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Nursing Program Health Record (Dallas County Community College)

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Completed 22 February 2021

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