Southwest Virginia Community College Nursing Program
Student Information, Physical Assessment and Immunization Record Form
Instructions:
• Student Information is to be filled out completely by the student
• Physical Assessment is to be filled out completely by a physician, physician’s assistant or nurse practitioner
• Immunization Record is to be filled out by the healthcare provider, signed and dated. Proof of immunization,
such as Health Department record or lab result must be attached. Do Not leave any item blank. It is the
student’s responsibility to make sure that the form and documentation are complete
Last name: ___________________________________ First name: ________________________________MI: ______
EMPL ID: _________________ Academic Year: ______________ Birth Date(MM/DD/YYYY): _____________________
Mailing Address: _________________________________________________________________________________
VCCS Email: _____________________________________________________________________________________
Cell Phone: ______________________________________Home Phone: ____________________________________
By my signature below, I authorize the Southwest Virginia Community College Nursing Program to release the
information on this form to clinical agencies as required by clinical affiliation agreements.
Student Printed Name: ________________________________________________________ Date: ________________
Student Signature: _________________________________________________________________________________
Physical Assessment
(to be completed by physician, physician’s assistant, or nurse practitioner)
Ht_________ Wt_________ T___________ P__________ R__________ BP___________ Vision__________
Please check in the YES or NO column to indicate status.
Any abnormalities of
the following areas?
If yes, Please Explain (include current treatments and
medications)
Provider Printed Name/Credentials: __________________________________________________________________
(MD, DO, NP, PA)
Provider Signature: _______________________________________________________________________________
Provider Phone: ________________________________________________ Date: ____________________________
