Nurses Assistant Physical Form – Fill Out and Use This PDF

NURSE ASSISTANT TRAINING/HOME HEALTH AIDE TRAINING

PHYSICAL EXAMINATION FORM

OFFICE MUST INCLUDE FACILITY STAMP ON BOTH PORTIONS OF THIS FORM

Name _______________________________________________Sex M______F _____Birthday _____/______/________

Address___________________________________City________________________Zip ___________Phone ____________________

Have you had a serious illness, injury, or surgery? If so, describe:

_____________________________________________________________________________________________________________________

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TO BE COMPLETED BY EXAMININING PHYSICIAN/NURSE PRACTIONER

PLEASE COMPLETE ALL SECTIONS

1.Current complaints or disabilities pertinent to the student’s education in the Nurses Assistant or Home Heath Aide Training

Programs.

_________________________________________________________________________________________________________________

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2.Medication used: Prescription and over the counter (Use back if necessary)

Name	Reason	Frequency
_____________________	______________________	____________________
_____________________	______________________	____________________

3.Significant medical history: Major illness, accidents, deformities, surgeries, back problems, hepatitis, etc.

_________________________________________________________________________________________

4.Examination Comments and Findings:

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Normal Physical, patient able to participate in class physical activities. (Circle one) YES NO

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The above named has no communicable, disabling disease or any health condition that would create a hazard to himself fellow employees, visitors or to patients at this time. He/She is able to perform the physical activities required for the program for which the individual is applying.

Medical Examiner: _________________________ Phone #______________________
Address: ___________________________________________
City/State/Zip: ______________________________________		Facility Stamp
Signature: _______________________________________Date___________
Physical (M.D.), or Physical’s Assistant signature
Student Signature ______________________________________________
I give permission to release a copy of this form to affiliating clinical facility.

……………………………………………………………………………………………………………………………………………………………

Name of Student: ______________________________________	Facility Stamp
Required Screening for Tuberculosis (Within 6 months of class)
PPD (Attach Report Form) Date given _________Date read ____________
PPD Results __________
Chest x-ray [only if P.P.D. is positive] Date ________Results __________
DOCTOR REPORT MUST ACCOMPANY ALL CHEST X-RAY RESULTS.