Name of Student: __________________________________

State College of Florida, Manatee-Sarasota

Division of Nursing and Health Professions
AS Nursing Program
***Certificate of Health***
FORM B

AS NURSING STUDENT:
This certificate must be completed and signed by your Healthcare Provider and uploaded by the due date. This
is an annual requirement of the AS Nursing program. It is the student’s responsibility to maintain clinical
compliance during the program.

To be completed by the student:

__________________________________________________________________________________________________________M________F______Other______
Last Name
First Name
Middle
Sex

___________________________________________________________________________________________________________
Home Address (Number & Street) City or Town
State Zip
Date of Birth

_____________________________________________________________________G00___________________________________
Home Telephone Number Cell Number

ID #

ALLERGIES:
Medication (circle one): Yes No If yes, please list medication(s), reaction and treatment: __________________________
__________________________________________________________________________________________________________
Food (circle one): Yes No If yes, please list the food(s), reaction and treatment: ____________________________
__________________________________________________________________________________________________________
Latex (circle one): Yes No If yes, what size gloves do you wear? ________________________________________
__________________________________________________________________________________________________________
Other (circle one): Yes No If yes, please list, reaction(s) and treatment: ___________________________________
__________________________________________________________________________________________________________
If yes, to any of the Allergies listed above do you carry an epi-pen (circle one)? Yes No

MEDICAL HISTORY:
Are you currently being treated for a medical issue (acute or a chronic condition) that could affect your ability to work safely in the
clinical setting (Hospital, Learning Lab and/or Simulation Center)? ____________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________

Are you currently being treated for a medical issue(s) (acute or a chronic condition) that you feel that your classroom faculty needs to
be aware of? ________________________________________________________________________________________________
____________________________________________________________________________________________________________
______________________________________________________________________________________________________

ADDITIONAL REMARKS OR INFORMATION FROM THE STUDENT:

_________________________________________________________________________________________________________
_________________________________________________________________________________________________________

____________________________________ _________________________________________________

1
Name of Student: _____________________________
Date Student Signature
Name of Student: __________________________________

REPORT OF HEALTH EVALUATION (page 2 of 2)

TO THE EXAMINING HEALTHCARE PROVIDER: Please review the student’s history and complete the physical form. This
student has been accepted or is currently enrolled in the AS Nursing program the information supplied will not affect his/her status. It
is strictly for the use of the program and will not be released without student permission.

PHYSICAL EXAMINATION:
Blood Pressure: _______________________ Heart Rate: ___________________________
Height: ______________________________ Weight: ______________________________
Vision: Normal _________________ Corrected Adequately ___________ Abnormal ____________
Hearing: Normal _________________ Corrected Adequately ___________ Abnormal ____________
Communication Skills: Normal _________________ Corrected Adequately ___________ Abnormal ____________
Gross Motor Skills: Normal _________________ Corrected Adequately ___________ Abnormal_____________
Adaptive Device Required Yes __________ No __________ N/A ____________
Fine Motor Skills: Normal _________________ Corrected Adequately ___________ Abnormal_____________
Adaptive Device Required Yes __________ No __________ N/A ___________

ADDITIONAL REMARKS RELATED TO THE ABOVE ASSESSMENT:

______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________

Examination of Yes Yes Comment if an Abnormal Assessment is Identified

the Body Systems Examined Examined
(No Abnormality
Abnormality was Identified
was Identified) (see comment)

Head

Eyes and Ears

Nose and Throat

Neurological

Cardiovascular

Respiratory

Gastrointestinal

Genitourinary

Musculoskeletal

Neuropsychiatric

Metabolic/Endocrine

Skin

Other (List)

Based on my examination of _________________________________________ (student’s name) and in my opinion this student:

Meets the Physical Requirements needed to work in a hospital environment for a 10 – 12hour clinical day that will require
lifting, reaching, transferring, pulling, turning, and pushing patients and standing for extended periods of time.
Yes _______ No _______
Meets the Behavioral/Psychological Demands needed to function successfully in the classroom setting and hospital
environment in the Nursing Program. Yes _______ No _______
2
If No to the above questions, please explain: ______________________________________________________________________
__________________________________________________________________________________________________________

Is on (a) prescription(s) medication(s) that WILL affect their ability to function safely in a clinical/hospital environment.
Yes ______ No ________ N/A ________
If Yes to the above question, please explain: ____________________________________________________________________
________________________________________________________________________________________________________

Healthcare Provider Signature: _______________________________________________Date: ___________________________

Healthcare Provider Name (Printed): ___________________________________________________________________________
Healthcare Provider License Number: __________________________________________________________________________
Address: _________________________________________________________________________________________________
Phone Number: _______________________________
3/2021