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School of Nursing, Midwifery & Physiotherapy Health Form for ERASMUS students conducting a placement at the Division of Nursing/Midwifery, University of Nottingham. Name: ___________________________________________________________________________ Current Academic Institution: ________________________________________________________ Date of Birth: ______________________________________________________________________ Dates of Proposed Attachment: ______________________________________________________ Placement Area(s): _________________________________________________________________ It is important that you are properly protected from infectious disease during your attachment. questionnaire below will help assess your fitness to attend the course of study. The All information you declare will remain confidential. PLEASE NOTE: It is your responsibility to take, and follow specialist advice if you are or you believe you may be infected with any blood borne virus including Human Immunodeficiency Virus (HIV). HEALTH QUESTIONNAIRE Please ask your Doctor or Occupational Physician, to complete the following details about your health. Your doctor must sign the statement at the back of the page. HEPATITIS B Evidence of Immunity Hepatitis B or absence markers of infectivity to of Please include originals, or copies of results of: Hepatitis B Antibody Level OR Hepatitis B Surface Antigen tests (if POSITIVE, include Hepatitis B āeā antigen test) Date Date TUBERCULOSIS Free from active infection Please attach certificate/evidence of being free from this infection within the last 12 months. MMR (Measles, Mumps, Rubella) Please include original or copy of Test VARICELLA Evidence of Immunity Please attach relevant certification showing one of the following: Definite recollection of Past infection Documented vaccination with two doses OR Result of Antibody titre to varicella Date Date Any serious medical condition DN-2.incoming HEALTH FORM Page 1 MEDICAL HISTORY Please tick relevant response Have you, at any time, suffered from: NO 1. 2. 3. 4. 5. YES REMARKS Depression, anxiety, nervous illness/breakdown Faints, fits or disease of balance or nervous system Allergies or sensitivities or reactions to immunisation Back problems Is there any other condition/disability you would like to declare? DECLARATION Student: I declare that the above answers are true and complete to the best of my knowledge and belief. Signature of Student: ____________________________________ Date: ____________________________________ Doctor: I certify that the information included about the above student is correct. Signed: ____________________________________ Name (Capitals): ____________________________________ Position: ____________________________________ DN-2.incoming HEALTH FORM Practice Stamp Page 2