St. Bernadine School of Allied Health
591 Summit Ave Suite 410, Jersey City, NJ 07306 | (201) 222-1116
Universal Medical Physical Form
Student Information
Student Name (Last, First, MI)
Date of Birth
Address
Check Program:
CNA
CHHA
CMA
PCT
Other: ________
Physical Examination (To be filled by Provider)
Height
Weight
BP
Pulse
General Appearance/Systems Review:
Is the student free from communicable diseases?
Yes
No
Is the student physically capable of performing the duties of a healthcare
student/professional (lifting, standing, etc.)?
Yes
No (Explain below)
Required Immunizations / Screenings
1. Tuberculosis Screening (PPD Mantoux or Chest X-Ray)
Step 1 Date Given: _________
Date Read: _________
Result: _________ mm
Step 2 Date Given: _________
Date Read: _________
Result: _________ mm
Chest X-Ray (if PPD positive): Date
_________ Result: __________________
2. MMR (Measles, Mumps, Rubella)
Dose 1 Date: _________
Dose 2 Date: _________
3. Varicella (Chicken Pox)
Date of Disease OR Vaccine: _________
4. Hepatitis B (Optional/Declination)
Dose 1: ______ Dose 2: ______ Dose 3:
______
5. Seasonal Flu Vaccine
Date: _________ (Required during flu
season)
6. Physical Exam Date
Date: _________ (Must be within 1 year)
Provider Name (Print) & License #
Clinic/Office Address & Phone
Signature
Date of Exam
Provider Office Stamp