EDINBORO UNIVERSITY
DEPARTMENT OF CONTINUING EDUCATION
NURSE AIDE TRAINING PROGRAM
REPORT OF HEALTH EVALUATION
THE EXAMINING PHYSICIAN OR NURSE: Please review the student’s health history and answer the questions on this
ORIGINAL form. This information is strictly for the use of Edinboro University’s Nurse Aide Training Program. It will not
be release without the student’s consent.
ALL QUESTIONS MUST BE ANSWERED.
STUDENT- FILL THIS PORTION OUT ENTIRELY
Last 4 digits of Social Security Number _________
Sex
M ____
F____
________________________________________________\___________________________________
LAST NAME
FIRST NAME MI
e-mail address
___________________________________________________________________________________
ADDRESS
CITY
STATE
ZIP
PHONE NO.
General Information
Height_________
Date of Exam_____________
Weight__________
Blood Pressure__________
Are there any abnormalities of the following? If you check yes, describe fully under comments.
NO
YES
NO
1. HEENT
6. Musculoskeletal
2. Respiratory
7. Metabolic/Endocrine
3. Cardiovascular
8. Neurological
4. Gastrointestinal
9. Integumentary
5. Genitourinary
10. Psychiatric Disorder
The Patient is able to lift a minimum of 40 pounds? ______ Yes
YES
______ No
Comments: _______________________________________________________________________________________
_________________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
EDINBORO UNIVERSITY
DEPARTMENT OF CONTINUING EDUCATION
NURSE AIDE TRAINING PROGRAM
NAME ___________________________________________
EMAIL ADDRESS
PHONE NUMBER __________________________
______________________________________
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#1)
TWO-STEP PPD IS REQUIRED
If there has not been a Mantoux test done within the past year, the 2-step method is required.
If one was done within previous 12 months, submit verification of that date, placement and result in addition
to this current PPD. (If one on file in nursing office, submit current PPD.)
Step #1
Date test performed: _________
R arm/ L arm _________
Initials of tester ________
Date test read: __________ Initials of reader _______ positive ____ negative____ (PPD) _____ mm of induration
STEP #2 IS TO BE GIVEN 7 – 21 DAYS AFTER STEP #1
Step #2
Date test performed: _________
R arm/ L arm _________
Initials of tester ________
Date test read: __________ Initials of reader _______ positive ____ negative____ (PPD) _____ mm of induration
If there is a history of a positive TB skin test in the past, attach documentation of that positive TB skin test,
evaluation and recent chest x-ray results.
Follow-up: Chest x-ray:
Date
____________
Results __________________________
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2)
Ten Panel Urine Drug Test Date ________
Comments if positive: ________________________
_____Positive
_____Negative
ATTACH A COPY OF THE LAB REPORT FOR DRUG SCREEN
Signature of Physician or Certified Registered Nurse Practitioner
X____________________________________________________________________________
Printed Name
__________________________________________________
Date __________________
Address ________________________________________________________________________________