Student Health Assessment

Please complete the confidential form below prior to your first clinical date at St. Anthony. 

• Yes
• No

Please upload a copy of all past immunizations, including all those received as an infant or child and / or you may continue to sections below. 

Please enter the date of your last flu vaccine if your Student Experience falls between October 1st through March 31st.

Hepatitis B vaccinations are not a requirement, but recommended for anyone at risk for exposure to blood and/or blood products. A declination must be completed if applicable. 

Stated history of Chicken Pox, two Varicella vaccinations OR a positive titer will be accepted.

• Students consistently scheduled for 5 or more hours per week are required to have 2-step TB skin test. At least one  step (skin test) must be completed within the 12 months prior to working at St. Anthony.
• If needed, students may obtain a TB skin test from the St. Anthony Employee Health Nurse for a fee of $25. 

Have you had any of these signs/symptoms in the last year?  (All questions must be answered.)

• Yes
• No

• Yes
• No

• Yes
• No

• Yes
• No

• Yes
• No

• Yes
• No

• Yes
• No

• Yes
• No

• Yes
• No

• Yes
• No

• Yes
• No
• I Don't Know

• Yes
• No
• I Don't Know

I certify that all of the statements provided here are true and correct to the best of my knowledge.