Medical Form for Holland College Health Programs
Admission/Office of the Registrar 140 Weymouth Street
| Type | 1629822412 |
| Size | 103 KB |
Referenced from: Health Clinics
Document text
Section titled “Document text”Admission/Office of the Registrar 140 Weymouth Street
Charlottetown, PE ~ C1A 4Z1
Tel: 902-629-4217 (1-800-446-5265)
Medical Form for Holland College Health Programs
Section titled “Medical Form for Holland College Health Programs”{The physician’s examination must be completed within 12 months of the Program Start Date.}
Applicant Name:
Phone No:
Address:
Month/Year of Birth:
/
Program (Please check one):
-
Primary Care Paramedicine
-
Advance Care Paramedicine
-
Resident Care Worker
-
Practical Nursing
This questionnaire is to be completed by a physician following an examination of the above applicant.
- Does the applicant suffer from any physical problems, which would require special consideration?
……
-
Yes
-
No
- Does the applicant suffer from any chronic physical illness? ………… ………… ………… …………
……
-
Yes
-
No
- Does the applicant suffer from any chronic emotional illness? ………… ………… ………… …………
……
-
Yes
-
No
- Does the applicant suffer from any communicable disease? ………… ………… ………… …………
……
-
Yes
-
No
- Does the applicant suffer from any skin disease? ………… ………… ………… ………… …………
……
-
Yes
-
No
- Does the applicant suffer from allergies? ………… ………… ………… ………… ………… …………
……
-
Yes
-
No
- Does the applicant suffer from any cardiovascular disease that would require special consideration?
……
-
Yes
-
No
- Does the applicant suffer from any respiratory disease that would require special consideration?
……
-
Yes
-
No
- Does the applicant suffer from any musculoskeletal disease that would require special consideration?
……
-
Yes
-
No
- Does the applicant suffer from any visual impairm
ent? ………… ………… ………… …………
……
-
Yes
-
No
- Does the applicant suffer from any hearing impairment?
………… ………… ………… …………
……
-
Yes
-
No
- Is there any factor not covered by the above questions which would affect the applicant ’ s suitability to successfully complete the above noted program?
Note: Please refer to the outline of physical requirements for the programs on the reverse side this medical form.
……
-
Yes
-
No
Physician declaration:
Section titled “Physician declaration:”After completion of an examination of the individual named above, it is my opinion that the ‘applicant’ is
-
Medically Fit, or
-
NOT Medically Fit ,
to undergo the training program with full regard to all the physical requirements indicated on the reverse side of this form.
Comments:
Date of Examination:
Physicians Signature:
Physician Contact Information: (Please Print)
Physician Name:
Business Phone No:
Clinic/Office Business Address:
The personal information requested on this form is collected under the authority of Section 31(c) of the PEI Freedom of Information and Protection of Privacy Act and will be protected under Part 2 of that Act. It will be used to assess the medical fitness of applicants to the Health programs at Holland College. If you have any questions about the collection or use of this information, please contact the Chief Privacy Officer at privacy@hollandcollege.com or 902-566-9542, 140 Weymouth Street, Charlottetown, PE, C1A 4Z1.
Information Regarding the Physical Requirements of the College Programs Identified on this Form
Section titled “Information Regarding the Physical Requirements of the College Programs Identified on this Form”Note to Physician and Applicant:
Section titled “Note to Physician and Applicant:”- The purpose of the information in this medical report is not to exclude the applicant, but rather to ensure that the applicant and the College are aware of any potential health concerns. When appropriate, applicants with health concerns are provided with the opportunity to demonstrate that they can meet the requirements of the program.
- Below is a brief description of the physical demands of the programs.
- The College also requires that students in these programs provide results of a TB test. Students must test negative for a TB skin test or a negative chest x-ray.
Primary Care and Advance Care Paramedicine Programs:
Section titled “Primary Care and Advance Care Paramedicine Programs:”The programs and the occupational field require students to lift, move and transfer clients under various conditions where the total body weight of the client plus the stretcher may exceed 200 lbs (90 Kgs). The students are required to care for and maneuver victims from settings which include stairs, vehicles, small spaces, and a variety of terrain under all sorts of weather conditions.
Resident Care Worker and Practical Nursing Programs:
Section titled “Resident Care Worker and Practical Nursing Programs:”The programs and the occupational field require students to lift, move and transfer clients. Students are also required to conduct frequent hand washing, use soaps and lotions for bathing clients and be exposed to cleaning and sanitizing chemicals. Students who suffer from food allergies should also be aware that they are required to assist in feeding clients and are therefore exposed to a wide variety of foods.