Kennesaw State University ~ WellStar School of Nursing

~ Physical Exam Requirements ~

Name_____________________________ Date of Birth_________________________________

KSU ID # __________________________ Phone Number_______________________________

KSU Email__________________________ Date of physical exam_________________________

Height________ Weight_________ Body Mass Index__________ Blood pressure_____________

Examined Normal Abnormal – Please include explanation of abnormality

HEENT
Thyroid
Lungs
Heart
Chest
Abdomen
Extremities
Allergic to: _____________________________________________________________________
Describe Reaction to allergy: _______________________________________________________

• 1st Step PPD date read_____________measurement of induration in millimeters_________

• 2nd Step PPD (initial PPD only) date read ____________ and induration (mm) _________
• Quantiferon Gold (date/results if positive PPD, attach labs)_________________________
►Chest x-ray (date and results, attach MD report) ____________________________________
►Current treatment for latent TB, please indicate medication dose, frequency and
duration_____________________________________________________________________

Provider signature for TB testing_______________________________ Date____________

Immunization History – Please list all dates
• Tetanus/Diphtheria/Pertussis (Tdap is required)________________________________
TD booster date _____________________________________________________
A POSITIVE TITER IS REQUIRED FOR HEP B
LAB REPORTS WITH VALUES MUST BE ATTACHED
• Varicella
Positive varicella titer date_____________________________________________
Or date of immunizations#1_______________________#2___________________
• MMR
Positive rubella titer date_______________________________________________
Positive measles titer date______________________________________________
Positive mumps titer date_______________________________________________
Or date of immunizations#1_______________________#2___________________
• Hepatitis B
Positive HepB titer date _______________________________________________
And date of immunizations#1______________#2_____________#3____________
Second series if negative titer#1__________#2____________#3_______________
I attest the student is able to participate in patient care.
Health Care Providers Signature: __________________________ Date: __________________
Health Care Provider’s Name (Print):_______________________________________________
Address: _______________________________________________________________________
Phone Number: _________________________________________________________________