MOUNTAIN VIEW COLLEGE Health Record Date Name: DOB: Last First Middle Month Day Year Address: Street City & State Zip Telephone: Home Work Cell or VM I certify that I have: Health Questionnaire: To be filled out by applicant. 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: Rev. 1.27.16 1.
4. 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: 5. 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: 6. Reliable personal transportation and ability to attend all classroom and clinical experiences, both on and off campus. Yes No If no, Explain: 7. 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: 8. Ability to function safely and professionally under various stressful conditions. Yes No If no, Explain: 9. 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: Rev. 1.27.16 2.
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 other conditions which might interfere with your ability to practice nursing? Yes No If yes, Explain: 3. List any prescription, 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). Once accepted to the nursing program, the following must be completed: Tuberculosis Screening: Submit documentation of testing with a physician s or nurse s signature or verification from the Health Facility. Intradermal PPD (Mantoux) within six (6) months, unless previously positive. Date Results Signature Physician or Nurse Chest x-ray- within one (1) year if PPD positive Date Results Physician s Signature Updates of tuberculosis screening will be required every 12 months while enrolled in the Mountain View College nursing program. Rev. 1.27.16 3.
Record of Required Immunizations List dates of immunizations or dates of lab results indicating seropositivity required. 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. Dates of Completed Series Titer where appropriate Copies of records presented to MVC nursing program Comments 1. Measles 2 doses since 12 months of age if born prior to January 1, 1957, or verification of immunity. 2. Mumps 1 dose since 12 months of age if born prior to January 1, 1957, or verification of immunity. 3. Rubella 1 dose since 12 months of age or verification of immunity. Individuals born prior to January 1, 1957, are NOT exempt. 4. TDAP 1 dose within past 10 yrs. 5. Varicella 2 doses are required. (If one dose was received prior to age 13, then only 1 dose is required. ) Confirmation of previous varicella disease signed by a physician, parent, or guardian may be accepted. 6. Hepatitis B vaccine series must be completed before any clinical rotation or positive titer if series previously completed. Initial dose: One (1) month: Six (6) months: No student may begin clinical rotations without verification of immunization status. Rev. 1.27.16 4.
PHYSICAL EXAMINATION: To be completed by physician, nurse practitioner or physician assistant. NAME Last First Middle DATE 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. GENERAL APPEARANCE Check each item in Normal appropriate column Eyes-ears-nose-throat Mouth, teeth, neck Abnormal Describe every abnormality in detail (attach sheet if necessary) Heart and Vascular Lungs Abdomen and Viscera Back, Vertebrae Extremities Skin Neurologic Laboratory and Diagnostic Data: (May attach copy.) Appropriate lab findings for this student: Name of Test Results Health Care Provider Signature Date Physical exam form will not be accepted without health provider signature or verification for each immunization and TB screening Rev. 1.27.16 5.
Laboratory and Diagnostic Data: May attach copy.) Appropriate lab findings for this student: Name of Test Results 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 Signature Date 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. Rev. 1.27.16 6.