PHYSICAL FORM
CNM Community College
Health Occupations
525 Buena Vista SE
Albuquerque, NM 87106
(505) 224-4111
Please make a copy for your own records
| Name: First Middle Last | SS# | |
| Address | Phone # | |
| Sex: _____M ______F | Birthdate: | Program |
REQUIRED IMMUNIZATIONS (LIST DATE LAST IMMUNIZED)
DATE DATE
Td (Tetanus/Diptheria):________________ MMR________________ OR
Rubella titer of 1:64 or higher_____
Tuberculin skin Test
(Must be within 1 year) Date___________
Reading________
If positive, chest x-ray required:
Date___________
| Hepatitis B | #1_____________ Date | #2_____________ Date | #3_____________ Date | Titer___________ Date |
| I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring hepatitis B virus (HBV) infection. I decline hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease. _________________________________ Waiver Signature | ||||
RECOMMENDED IMMUNIZATION
| Hepatitis A | #1_______________ Date | #2_______________ Date |
PHYSICAL EXAMINATION
(Must be within 2 years)
| HT________________ | WT________________ | B/P________________ | Pulse_____________ |
| Vision: Without glasses With glasses or contacts Hearing: | R________________ R________________ R________________ | L_________________ L_________________ L_________________ |
| NORMAL | ABNORMAL | REMARKS | |
| Head, face, scalp | |||
| Teeth | |||
| Nose, septum, obstruction | |||
| Mouth, throat, tonsils | |||
| Speech defects | |||
| Neck – Thyroid | |||
| Chest | |||
| Lungs | |||
| Breasts | |||
| Heart | |||
| Abdomen – Hernia | |||
| Women: Pelvis (if indicated) | |||
| Men: Genitalia-Hernia | |||
| Musculo-skeletal | |||
| Posture - Spine | |||
| Joints – Feet | |||
| Reflexes | |||
| Skin | |||
| Blood Work if indicated: CBC ____________________ Basic Chemistry Profile___________________ | Urinalysis if indicated: Glucose_________ Blood___________ Protein__________ Microscopic if indicated________ (attach results) | ||
Please list any conditions that might impact the student’s/patients’ safety: (example: visual/hearing impairment, pregnancy.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Is student able to lift 50 lbs or more? Yes ? No ?
Does student have a communicable disease? Yes ? No ?
Does student have a documented latex allergy? Yes ? No ?
Please check one:
___Student is approved for full participation in clinical areas.
___Student is approved for participation in clinical with the following limitations.______________________________
_____________________________________________________________________________________________
Practitioner’s Signature________________________________________________________
Facility:__________________________________ Phone #:__________________________
Please make a copy for your own records
R112200
