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    Nursing Medical Record Form

    Uploaded by

    Isabela Sophy
    Medical check up form

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Nursing Medical Record Form

    Uploaded by

    Isabela Sophy
    2 views2 pages
    Medical check up form

    Original Title

    Nursing-Medical-Record-Form

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

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    Medical check up form

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    2 views2 pages

    Nursing Medical Record Form

    Uploaded by

    Isabela Sophy
    Medical check up form

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Office of Health Services

    Medical Arts Building, Room, MC-02


    222-05 56th Avenue, Bayside, New York 11364-1497
    Telephone (718) 631-6375 • Fax (718) 631-6330

    Medical Record for Nursing


    Please submit TWO copies and original of all material to Health Services. Health Services will NOT make copies for you.
    Whiteout renders forms null and void.
    — To be completed by Student —

    Student lnformation (Please print):


    CUNYFIRST ID No.: _____________________________________________________ Last four digits of S.S. No.: _____________________

    Gender: Male ________ Female ________ Trans. (specify) ________________________ Other (specify) ________________________

    Last Name: _________________________________ First Name: ________________________________ Birth Date: ______ /______ /______

    Address: ______________________________________________ City _____________________________ State ______ Zip ________________

    E-mail: __________________________________________________________________________________

    Home Phone No.: _______-________–_______________ Cell No.: _______-________–_______________


    Emergency Contact lnformation:

    Last Name: _________________________________ First Name: ________________________________ Relationship: ___________________

    Home Phone No.: _______-________–_______________ Cell No.: _______-________–_______________

    Check any conditions that apply and if medications are taken for that condition.
    Condition Yes Meds. No Condition Yes Meds. No

    Allergies    Heart   
    Asthma    Injuries   
    Cancer    Kidney   
    Seizures    Musculoskeletal   
    Diabetes    Psychological   
    Drug/ Alcohol Abuse    High Blood Pressure   
    Ears/Nose/Throat    STDs/STls   
    Neurologic    Thyroid   
    Fainting    Tuberculosis   
    Gastro-intestinal    Other   
    Briefly describe any condition checked “yes” above and list subsequent medications: ________________________________________
    _________________________________________________________________________________________________________________________
    List any surgeries or conditions not mentioned above and list subsequent medications: ______________________________________
    _________________________________________________________________________________________________________________________

    Check any physical handicap and/or condition that applies.

    Wheelchair bound  Use of crutches or braces  Neurologic impairment  Speech Impediment 


    Blind or Partially Sighted  Deaf or Hard of Hearing 
    Briefly describe any physical handicaps: __________________________________________________________________________________
    _________________________________________________________________________________________________________________________
    Physical Examination
    Please submit TWO copies and original of all material to Health Services. Health Services will NOT make copies for you.
    Whiteout renders forms null and void.
    — To be completed by Health Practitioner (MD, DO, NP, or PA) —

    Student lnformation (Please print):

    Last Name: _________________________________ First Name: ________________________________ Birth Date: ______ /______ /______

    Last four digits of S.S. No.: __________________

    Blood Pressure: ___________________ Heart Rate: _________________ Height: _________________ Weight: ________________

    Vision OU: ______________ Vision OD: ______________ Vision OS: ______________

    Influenza Vaccination Date: ______ /______ /______ Lot #: ____________________ Expiration Date: ____________________

    System Normal Abnormal Remarks (describe abnormalities)

    Head/Neck Normal Abnormal Remarks

    Eyes/Ears Normal Abnormal Remarks

    Integumentary Normal Abnormal Remarks

    Skeletal Normal Abnormal Remarks

    Muscular Normal Abnormal Remarks

    Digestive/ Abdomen Normal Abnormal Remarks

    Lymphatic Normal Abnormal Remarks

    Respiratory Normal Abnormal Remarks

    Endocrine Normal Abnormal Remarks

    Neurologic Normal Abnormal Remarks

    Circulatory/Cardiac Normal Abnormal Remarks

    Genitourinary Normal Abnormal Remarks

    Psychological/Emotional Normal Abnormal Remarks

    Is student able to perform nursing tasks?  Yes  No


    If no, please describe why: _______________________________________________________________________________________________
    _________________________________________________________________________________________________________________________

    Is there any psychological or emotional condition(s) for which student is being treated?  Yes  No
    If yes, please describe: ___________________________________________________________________________________________________

    Health Practitioner Name: ________________________________________ Title: _____________________ License No.: ________________

    Address: ______________________________________________ City _____________________________ State ______ Zip ________________

    Office Phone No.: _______-________–_______________ Fax No.: _______-________–_______________ Health Practitioner Stamp Required
    (MD, DO, NP, or PA)

    Examination Date: ______ /______ /______


    05/2018 18-677 ADA

    Health Practitioner Signature ____________________________________________________________

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