Fillable VERIFICATION OF STUDENT HEALTH HISTORY & PHYSICAL EXAM (Berkshire Community College)

Fill Online, Printable, Fillable, Blank VERIFICATION OF STUDENT HEALTH HISTORY & PHYSICAL EXAM (Berkshire Community College) Form

Use Fill to complete blank online BERKSHIRE COMMUNITY COLLEGE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

VERIFICATION OF STUDENT HEALTH HISTORY & PHYSICAL EXAM (Berkshire Community College)

On average this form takes 4 minutes to complete

The VERIFICATION OF STUDENT HEALTH HISTORY & PHYSICAL EXAM (Berkshire Community College) form is 1 page long and contains:

  • 1 signature
  • 4 check-boxes
  • 10 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Berkshire Community College

BROWSE BERKSHIRE COMMUNITY COLLEGE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
VERIFICATION OF STUDENT
HEALTH HISTORY & PHYSICAL EXAM
Physical Therapist Assistant Program
Students admitted to the Physical Therapist Assistant Program are required to have their medical
provider complete this form.
Students participating in BCC’s Physical Therapist Assistant Program must be capable of performing the
Physical Therapist Assistant Program’s Essential Functions with or without reasonable accommodation*.
The Physical Therapist Assistant Program’s Essential Functions establishes the minimum physical and
mental requirements for all students participating in the program’s courses and clinicals. A list of the
program's essential functions is available on the reverse side of this form.
Student Information
Student Name: ______________________ DOB: ___________________BCC ID___________
Medical Provider Verification
Based on my review of the student’s health history and medical examination of the student and
review of the Physical Therapist Assistant Program’s Essential Functions (on reverse), this
student is:
☐ Cleared for all classroom/lab/clinical participation without restriction
☐ Not cleared at this time; will require a meeting with the Disability Service Center to assess for
the applicability/appropriateness of accommodations *
☐ Not cl
eared at this time; short term limitation that will require a follow-up visit to the
physician: List restrictions:
☐ Not cleared
Medical Provider Information
Medical Provider: ________________________________________ Telephone: _____-_____-______
Office/Practice: __________________________________________ Fax: _____-_____-______
Address:________________________________________________________________________________
Street City State Zip code
Date of Physical Exam: ___________
Medical Provider Signature: _______________________________________ Date ______________
Please return completed form to: Berkshire Community College
Nursing, Health and Immunization Office, Room H310
1350 West Street, Pittsfield, MA 01201
Telephone: 413-236-4609; Fax: 800-724-9943
Email: medicalrecords@berkshirecc.edu
*A student with a disability who may need accommodations should contact the Disability Resource Center at
413-236-1614.
Rev. May 1, 2020
click to sign
signature
click to edit
Rev. May 1, 2020
Essential Functions: Physical Therapist Assistant Program
Berkshire Community College seeks to provide equal access to its programs, services and activities for all
people. The Essential Functions of a student enrolled in the Physical Therapist Assistant Program
requires that the student, with or without reasonable accommodations, must be able to:
Categories of
Essential Functions
Example of Technical Standard
1
Critical Thinking/ Problem
Solving Skills
• Collect, interpret and integrate information and make decisions.
• Read and comprehend relevant information.
• Identify cause/effect relationships in the provision of health care.
• Respond calmly and effectively to emergencies.
• Use effective teaching, learning and test taking strategies.
2
Interpersonal Skills
• Embody the spirit of cooperation and collegiality, employing basic
conflict management skills as situations require.
• Establish positive, supportive, effective and harmonious relationships in
diverse settings, with diverse patient/client and colleagues.
3
Behavioral/Emotional/
Social Coping Skills
• Respond appropriately to stressful environments or during impending
deadlines
• Concentrate on professional duties without distraction in all settings.
• Set priorities and perform all aspects of therapy services in fast-paced
academic and clinical situations.
• Cope effectively with psychosocial issues involving illness, disability and
death without hindering effective performance of duties.
4
Communication Skills
• Communicate effectively in English using verbal, non-verbal and written
formats.
• Re
cognize, interpret and respond to non-verbal behavior.
5
Physical Mobility/Motor
Skills
• Demonstrate adequate coordination, balance speed and agility to assist
and safely manage patients who are walking on level and unlevel terrain
to include: stairs, ramps, grass/gravel, curbs, and diverse home flooring.
• Mo
ve, adjust and position patients or equipment which involves
bending, stooping freely to the floor, reaching overhead, lifting, pulling
or guiding a weight of 200
pounds.
• Maintain and/or transition between postures that may include,
standing, kneeling, walking and crawling for up to 90 minutes without
rest.
• Ma
nipulate devices with sufficient dexterity bimanually
• Manipulate small nuts/bolts, and equipment settings with sufficient
hand strength and dexterity.
6
Sensory Abilities
• Visual–recognize and interpret facial expressions and body language
and patient posture, identify normal and abnormal patterns of
movement, discriminate color changes and interpret and assess the
envi
ronment up to 20 feet; read or set parameters on physical therapy
equipment.
• Auditory–recognize and respond to soft voices or voices under
protective garb, auditory timers, equipment/emergency alarms, and
effecti
vely use devices for the measurement of vital sign and breather
sounds. Be able to hear patients and respond to patient critical
needs
when not in direct line of site.
• Ta
ctile – palpate a pulse and detect changes or abnormalities of surface
texture, skin temperature, body segment contour, muscle tone and joi
nt
movement.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

VERIFICATION OF STUDENT HEALTH HISTORY & PHYSICAL EXAM (Berkshire Community College)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 26 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document