To Be Completed by Student Prior to Physical Examination

OKLAHOMA HIGHER EDUCATION

MEDICAL HISTORY

(To be completed by student prior to physical examination)

Name______Age______Sex______

(last) (first)

College______Fr _____ Soph ______Date of Birth ______

School Address 2801 North Main St. Altus, Oklahoma 73521 Phone __580-477-7830______

Person to notify in case of emergency

Parent ⁯ Guardian ⁯ Spouse ⁯ ______Phone ______

Present address ______

Hospital or Medical Care Insurance______

1. Have you ever had or do you now have any serious medical or mental illness? Yes___ No____

(If yes, please list illness and year of occurrence.) ______

______

2. Have you ever had any type of surgery? Yes _____ No _____

(If yes, describe and give year.) ______

______

3. Are you currently being treated for ongoing medical condition? Yes_____ No_____

(If yes, please list condition and physician who is treating.) ______

______

4. Are you currently taking any medications? Yes_____ No _____

(If yes, please list ALL medication and dosage- include Over The Counter Medications/Herbs/Vitamins.) ______

______

5. Are you allergic to any medications? Yes_____ No______Foods? Yes_____ No______Latex? Yes_____ No______

(If yes, please list.) ______

______

Note: Upon written request, a copy of this form may be forwarded to Health Services of another institution upon transfer.

DATE ______SIGNATURE OF STUDENT ______

This institution in compliance with Title VI and Title VII of the Civil Rights Act of 1964, Title XI of the Education Amendments of 1972 Section 503 of the Rehabilitation Act of 1973, Section 402 of the readjustment Assistance Act of 1974, the Americans with Disabilities Act of 1990, and other Federal laws and regulations, does not discriminate on the basis of race, color, national origin, sex, age, religion, physical or mental disability, or status as a veteran in any of its policies, practices , or procedures. This includes but is not limited to admissions, employment, financial aid, and educational services.

PHYSICAL EXAMINATION

Name______Date______

(last) (first) (middle)

Laboratory Results (please attach lab results to this document)

UA______Hgb ______Hct______

Immunizations/Titer Levels *This is a required component of the student’s clinical requirements for Western Oklahoma State College Nursing Department. **A copy of the immunization record and numerical titer lab results must be attached.

Date of last immunization: Tetanus ______Polio ______MMR______

(date 1st) (2nd)

Titer Results: Rubella:______Varicella:______Rubeola: ______Mumps______

Date of Hepatitis B:______

1st 2nd 3rd Titer Results

Tuberculin skin test: Type of test ______Date Given______Results______

(Current Tuberculin skin test required) Results Date read By whom

Summary of student’s health:

A. Physical: ______

B. Mental: ______

C. Recommendations for follow up: ______

I certify that this applicant is physically and mentally capable of participating in the clinical and classroom setting for Western Oklahoma State College’s Nursing Program.

STUDENTS MUST Signature of physician______Date______UPLOAD DOCUMENTS Address ______

TO: ______