Student Health Assessment

Prior to your first clinical date at St. Anthony, please complete the confidential form below.

All fields marked with * are required.

St. Anthony Regional Hospital Student Health Assessment

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

Immunization & Vaccination History

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. 

Influenza Vaccine

Seasonal flu shots (October 1st through March 31st) are required for any student that comes into St. Anthony Regional Hospital during flu season. 

Measles, Mumps, Rubella (*MMR) A total of two MMR's or a blood test (titer) showing positive immunity is required.
Hepatitis B

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. 

Varicella (Chicken Pox)

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

Tuberculosis (Please provide official TB skin test results)
  • 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. 

Tuberculosis Screening (REQUIRED) Answer each question

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

Past Training Received

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