Fillable Southwest Virginia Community College (SWCC) Nursing Program Student (Southwest Virginia Community College)

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Southwest Virginia Community College (SWCC) Nursing Program Student (Southwest Virginia Community College)

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The Southwest Virginia Community College (SWCC) Nursing Program Student (Southwest Virginia Community College) form is 2 pages long and contains:

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SWCC Nursing Program Student Statement of Health Form Page 1 of 2
Southwest Virginia Community College (SWCC) Nursing Program
Student Statement of Health
(To be completed by student and uploaded to CastleBranch by the stated deadline. This form must be
submitted annually while continuously enrolled in the SWCC nursing program).
Academic Year: Empl ID:
Name:
Mailing Address:
Cell Phone: Home Phone:
VCCS Student Email:
Indicate if you have ever been diagnosed or treated or are currently under care for any of the
following. Please indicate with a Y (yes) or N (no). Provide additional information as indicated on
back of form.
Condition
Explanation
Condition
Explanation
Asthma or any other
respiratory problems
Kidney Problems
Bladder
Low blood sugar
Blood disorders:
(hemophilia, sickle cell
anemia, etc.)
Musculoskeletal Problems
Cardiac
Pregnant
Diabetes
Neurological problems
(gait, smell, touch)
Fainting/Dizziness
Seizures
If yes, date of last seizure:
Hearing Problems
Vision problems (wear
Glasses or contacts)
High Blood Pressure
Other medical or
psychiatric problems
Are you under medical care for any of the conditions circled above? If yes, explain
(provide additional information on back of form)
□ Yes □ No
List name and purpose of any medications you are taking, including OTC.
Do you have any health problems that may interfere with your ability to function as
described in the SWCC student handbook. If yes, (Provide additional information
on back of form)
□ Yes □ No
Describe your general health □ Excellent □ Good □ Fair □ Poor
List drug, food or other allergies (i.e. latex allergy) and any medical attention that may be required in an emergency
situation.
Date of Annual PPD:
Name and Phone Number of Physician or Nurse Practitioner:
SWCC Nursing Program Student Statement of Health Form Page 2 of 2
EBOLA SCREENING
Have you traveled to an Ebola virus affected area (Guinea, Liberia, Sierra Leone, Mali) in the 30 days prior to
beginning a clinical rotation.
□ Yes □ No
I agree to notify the SWCC faculty and the clinical agency if I have been in contact with an individual who is
sick and has traveled to an Ebola virus affected area in the 30 days prior to a clinical activity.
Initial_____________
EMERGENCY CONTACT INFORMATION:
In case of emergency, I give the Southwest Virginia Community College Nursing Program
permission to obtain medical assistance and to notify my emergency contact person(s).
Signature of Student: Date
Emergency Contact Name:
Address:
Phone Number(s):
BY MY SIGNATURE BELOW, I VERIFY THAT THE INFORMATION PROVIDED
ON THIS FORM IS A TRUE AND ACCURATE REPORT OF MY HEALTH STATUS
AND I AUTHORIZE THE SOUTHWEST VIRGINIA COMMUNITY COLLEGE
NURSING PROGRAM TO RELEASE THIS INFORMATION TO THE AGENCIES
WHERE I HAVE CLINICAL LABORATORIES.
Student Signature: Print Name: Date:
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Southwest Virginia Community College (SWCC) Nursing Program Student (Southwest Virginia Community College)

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Completed 8 October 2020

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