Merrillville - Valpo - Lafayette - LaPorte - Michigan City
Med Ed, Inc.10971 Four Seasons Place # 118 (Mailing address only, classes at various locations)Crown Point, IN 46307ph: 219-661-8773 alt: firstname.lastname@example.org
FYI, any TB or Physical Form can be used
Student is taking nurse aide class.
BP_____ WT______ HEIGHT______
(student circle yes or no below)
Applicants Physical History:
1. Have you ever had an injury to
your back? YES NO
2. Any back surgery/treated for
back issues? YES NO
3. Have you ever had any other
injuries? YES NO
4. Do you have any physical defects
or disease? YES NO
5. Do you have any hearing or
speech defects? YES NO
If answer "YES" to any above,
_____________________________________________________________________I understand that misrepresentation
of facts above or on this form may
be reason for dismissal.________________________ ______________Student Signature DateHealth care personnel statement:
I find this person capable of
physically performing the duties
related to nurse aide training.
Student must be aware of those
duties that they can or cannot do.
__________________________________Person doing Physical
Date of exam_______________
PRINT OUT THIS FORM
-TAKE TO YOUR Dr.
Med Ed phone: 219-661-8773
Med Ed fax: 1-800-861-2030
If you have TB & Physical on 1st day your class will cost $900.... If you do NOT have TB & Physical on 1st day, your class will cost $1000 and you will get your TB & Physical with Med Ed.
See message at bottom of this page
TB TEST DATE GIVEN_______________RFA/LFA
person adminstering TB test______________________
Results of this TB test____________________
person reading TB test __________________________
Please give student copy of this and also fax to Med Ed: 800-861-2030
Copyright 2003 Med Ed, Inc.
All rights reserved.