HEALTH EVALUATION for ____________________________________________________
Applicant name – please print
"ALL APPLICANTS MUST SUBMIT A HEALTH STATEMENT FROM THEIR PHYSICIAN INDICATING THEY ARE IN
GOOD HEALTH AND ABLE TO SAFELY ENGAGE IN WORK THAT WILL INVOLVE LIFTING. ALL STUDENTS MUST
HAVE A NEGATIVE PPD TB SKIN TEST OR CHEST X-RAY PRIOR TO ADMISSION TO THE COURSE. STUDENTS
AND INSTRUCTORS WILL MEET ALL HEALTH REQUIREMENTS OF THE LONG TERM CARE FACILITIES WHERE
THEY ARE ENGAGED IN CLINICAL FIELD PRACTICUMS."
The above statement is the Health Policy of the American Red Cross.
For admission to the Nurse Assistant Training Program, please complete the following:
TO BE FILLED OUT BY APPLICANT:
1. Are you presently in good health? If not, explain
2. Have you had any serious illness or injury during the past year? If yes, please explain
3. Are you currently taking any medication? What and for what reason
4. Have you ever had a back injury? What happened and when
5. Are you pregnant? Yes No
I certify that the above statements are true.
Date_____________________ Signature of Applicant _____________________________________
American Red Cross
Madison/Marshall Co. Chapter
•
1101 Washington Street
•
Huntsville, AL 35801
CERTIFIED NURSE ASSISTANT HEALTH
EVALUATION
TO BE
FILLED OUT BY PHYSICIAN:
HEALTH
EVALUATION FORM FOR
______________________________________
Temperature Blood Pressure
Height Weight
I find
this person to be free of any obvious communicable
disease and physically able to perform the duties of a
nurse assistant.
This
individual does not have any medical condition that
limits or impairs lifting (scoliosis, pregnancy,
osteoporosis, etc) especially the ability to lift 50 or
more pounds.
_________________________________________________________________________
Date Signature of Physician or Nurse Printed
name of Office or Health Dept.
THIS FORM MUST BE SUBMITTED TO THE INSTRUCTOR PRIOR TO ATTENDING CLINICAL TRAINING.
PLEASE SUBMIT WITHIN THE FIRST TWO WEEKS OF CLASS!