Physical Exam Form

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Student lnformation:

Last Name

Street Address

City

State

Siened Statement of

As a Healthcare Provider, I have completed the examination required for the above named student prior to the start the clinical component for nursing school.

"FIT FOR PRACTICE"

of

(student name) is fit physically, My signature below verifies tfrat tr$6 /\(C0ll,tfq,/{,/ role of the nursing student in the clinical emotiJnally, and mentally able to coilpt.t" ttE .tiritii requirements for the setting. This includes but is not limited to: f the ability to lift and move an estimated weight equal to 35 pounds (greater than 35 pounds done with assistance or hrts)

Please slelect one of

thefollowing:
(pleuse specify)

L/

Fitfor Practice meeting all requirements Fitfor Practice with the following Restrictions:

Does not meet fhe requirements

for"

Fit for Proctice" without a likelihood of an iniury to tlte student.

H e altlt cure Pr ovider Info rmatio n :

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f

hnA.

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Signature of Healthcar"

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