Student’s Name: __________________________ PART I QUESTIONAIRRE –STUDENT All items require a or response. Incomplete forms will be returned and the “yes” “no” student will relinquish his/her position in the nursing program. Check to the right of each item. If explain as appropriate using the back of the page, if necessary. “yes”, Yes No 26. Heart/blood pressure medications PAST ILLNESSES: 27. Tranquilizers Hospitalization(s) 28. Insulin (date, reason) 29. Antidepressants (give name) Operation(s) (date, type) 30. Allergy injections 31. Other (specify) 3. Serious accident HAVE YOU EVER HAD: Yes No 4. Serious illness 32. Migraines (diagnosed by 5. Emotional problems MD) 6. Psychiatric treatment 33. Seizure disorder Other significant health problem 34. Paralysis or disability (specify) 35. Thyroid problems COMMUNICABLE DISEASES: Yes No 36. High blood pressure (give dates) 37. Rheumatic 8. Chicken pox (varicella) 38. Heart murmur (diagnosed by 9. Malaria MD) 10. Tuberculosis 39. Mitral valve prolapse 11. Poliomyelitis 40. Asthma 12. Diphtheria 41. Stomach or duodenal ulcer 13. Scarlet fever 42. Colitis/ileitis 14. Mononucleosis 43. Irritable bowel 15. Mumps 44. Arthritis or joint disease 16. Measles (rubeola) 45. Hepatitis 17. Rubella 46. Kidney disease/bladder 18. HIV infection problems 19. (specify) 47. High cholesterol ALLERGIES: Yes No 48. Back problems 20. Penicillin 49. Eating disorder (type) 21. Other antibiotics (give names) 50. Diabetes medications (give names) 51. Skin problems 23. Latex 52. Tumors (malignant or nonmalignant) 24. Life threatening reaction to bee stings, food, etc. 53. Anemia 25. Do you carry epinephrine pen? 54. Hernia DO YOU CURRENTLY TAKE: Yes No 55. Ear infections
Student’s Name: __________________________ PART I –STUDENT QUESTIONAIRRE All items require a “yes” or “no” response. Incomplete forms will be returned and the student will relinquish his/her position in the nursing program. Check to the right of each item. If “yes”, explain as appropriate using the back of the page, if necessary. Yes No PAST ILLNESSES: Hospitalization(s) (date, reason) Operation(s) (date, type) 3. Serious accident 4. Serious illness 5. Emotional problems 6. Psychiatric treatment Other significant health problem (specify) COMMUNICABLE DISEASES: (give dates) Yes No 8. Chicken pox (varicella) 9. Malaria 10. Tuberculosis 11. Poliomyelitis 12. Diphtheria 13. Scarlet fever 14. Mononucleosis 15. Mumps 16. Measles (rubeola) 17. Rubella 18. HIV infection 19. (specify) ALLERGIES: Yes No 20. Penicillin 21. Other antibiotics (give names) medications (give names) 23. Latex 24. Life threatening reaction to bee stings, food, etc. 25. Do you carry epinephrine pen? DO YOU CURRENTLY TAKE: Yes No 26. Heart/blood pressure medications 27. Tranquilizers 28. Insulin 29. Antidepressants (give name) 30. Allergy injections 31. Other (specify) HAVE YOU EVER HAD: Yes No 32. Migraines (diagnosed by MD) 33. Seizure disorder 34. Paralysis or disability 35. Thyroid problems 36. High blood pressure 37. Rheumatic 38. Heart murmur (diagnosed by MD) 39. Mitral valve prolapse 40. Asthma 41. Stomach or duodenal ulcer 42. Colitis/ileitis 43. Irritable bowel 44. Arthritis or joint disease 45. Hepatitis 46. Kidney disease/bladder problems 47. High cholesterol 48. Back problems 49. Eating disorder (type) 50. Diabetes 51. Skin problems 52. Tumors (malignant or nonmalignant) 53. Anemia 54. Hernia 55. Ear infections
TC-Nursing-Graduate-Program-Forms-Appendices-160630-1.docx