EMPLOYEE HEALTH SERVICE 600 Highland Avenue, Madison, WI 53792 Mail Code 6715 (608) 263 7535 FAX: (608) 262 7284 HEALTH ASSESSMENT FULL NAME DATE (LAST) (FIRST) (MIDDLE) HOME ADDRESS (STREET) (CITY) (STATE) (ZIP) HOME TELEPHONE BIRTH DATE (AREA CODE) EMAIL ADDRESS COUNTRY BORN PRIMARY HEALTH CARE PROVIDER OR CLINIC (NAME) (ADDRESS) (PHONE) TO BE COMPLETED BY EHS STAFF UNIT/DEPT JOB TITLE SHIFT FULL TIME PART TIME PERMANENT LTE START DATE: PLEASE ANSWER ALL THE QUESTIONS TO THE BEST OF YOUR KNOWLEDGE. COMPLETE THE QUESTIONNAIRE AND BRING IT WITH YOU FOR YOUR SCHEDULED APPOINTMENT. 1. Health conditions and hospitalizations (describe and give year): 2. Operations (describe and give year): 3. Major injury (describe and give year): 4. Allergies (including reactions to drugs): 1
Latex Allergy: Do you have an allergy to any rubber/latex products? yes no unsure If yes: Have you been tested/evaluated by a health care provider for this allergy? List the products you are allergic to: Describe the type of reaction you have: Exposures: If no: Have you had any skin rashes or breathing problems after handling or being exposed to any of the following products? Rubber gloves: Yes No Reaction: Balloons: Yes No Reaction: Other rubber products Yes No Reaction: Circle any foods below that cause hives, itching of the lips or throat, or more severe symptoms when you eat or handle them: avocado kiwi banana chestnut other nuts other foods Type of exposure and date(s) Radiation Solvents Noxious fumes and/or gases yes no unsure date(s) yes no unsure date(s) yes no unsure date(s) Comments: Include; where exposed, nature of exposure, follow up tests/examinations etc. Have you been exposed to blood or body fluids in the course of your work through needlestick/sharps injuries or mucous membrane exposures? yes no Date(s) If yes, have you been tested for HIV and counselled regarding the proper follow up? yes no Comments: Skin Test: Previous TB Skin Test yes no o Most recent TB skin test Date Result Positive TB Skin Test yes no Date of Positive Test BCG (vaccine for TB) yes no unsure Date TB Have you ever taken medication (i.e. INH) or other medications for a positive TB skin test or active tuberculosis? yes no If yes: Date 2
Chest X ray for TB yes no Date Result Immunizations: (MANDATORY FOR EMPLOYMENT) Please provide specific dates (day/month/year) of immunization and/or titer results for the following childhood diseases and bring official documentation. (Sources of information to assist you would be: Immunization records from parents, health care provider office, or previous health care employer). Immunization Dates MMR Vaccine 1. (Measles Mumps Rubella) 2. Titer Date and Results OR Measles (Rubeola) Mumps Rubella (German Measles) Chicken Pox (Varicella) 1. OR 2. Diphtheria/Tetanus 1. (dt or Tdap) Hepatitis B Vaccine 1. 2. 3. Influenza Vaccine Meningococcal Current Health Practices: Please circle "yes" or "no" or fill in the blanks 1. Medications: Prescriptions: Non Prescription (i.e., aspirin, vitamins, etc.): 2. How often have you consumed 4 or more alcoholic drinks in a day in the last year? 3. Recreational drug use: yes no Type Amount 4. Tobacco use: yes no Type Amount Quit Attempts Are you interested in quitting? yes no 5. Exercise: (Type/Amt) 3
REVIEW OF SYSTEMS INSTRUCTIONS: Please check yes", "no" or "unsure" depending on whether you have had a SIGNIFICANT history or RECENT problem with any of the listed items. Recent weight change Fever/chills/night sweats Lumps/masses/tumors Dizziness/light headedness Fainting Headaches Itching/Hives Rashes/Skin problems Thyroid Disorder Cancer Easy bruising or bleeding Fatigue History of Blood Transfusions Glaucoma Blurred or double vision Use glasses or contact lenses Loss of hearing Ringing in ears Trouble with nose or sinuses History of X ray therapy to head or neck Neck pain Back pain Joint problems Muscle weakness Use a brace or splint Carpal tunnel syndrome General Eye, Ear, Nose, and Throat Musculoskeletal 4
Cough Difficulty Breathing Sputum/phlegm production Pneumonia or pleurisy Shortness of breath with activity Wheezing or asthma Respiratory Palpitations Chest pain Heart disease High blood pressure Ankle swelling Blood clots Abdominal pain Nausea or vomiting Liver disease/hepatitis Jaundice Diarrhea Spleen removed? Pain or burning with urination Blood in urine Are you pregnant? Seizures Tremor Difficulty with walking Stroke Memory loss Black out spells Dizziness/Vertigo Anxiety Cardiovascular Gastrointestinal Genitourinary (both sexes) Neuropsychiatric 5
Depression Difficulty sleeping Hospitalization for psychiatric problems Sought professional help about a nervous disorder, mental health concern or emotional health concern Sought professional help for drug/alcohol problems Any other concerns you wish to discuss? Yes/No Describe Work History 1. Please list below the three kinds of work you have done most in your life so far (most recent first) 1. 2. 3. 2. Have you ever had a job related injury or illness? yes no If yes, briefly describe 3. Have you ever received compensation for any job related injury or illness? yes no If yes, provide employer; dates and describe injury 6
Answer each of the following questions. Not all questions may apply to your position and will be discussed at your appointment. Do you have, or have you ever had, any of the following? (Please check all that apply) Question Yes No Difficulty sitting for long periods Difficulty moving or lifting patients Difficulty with lifting objects weighing up to 50 pounds Difficulty with repetitive lifting, bending, squatting, twisting, reaching, pushing, pulling, standing, or walking Difficulty with prolonged standing Problems with working with chemicals, soaps or detergents Problems working in areas with dust or fumes Difficulty with stairs ladders or heights Difficulty with tolerating heat, cold or dampness Difficulty with lifting objects weighing up to 100lbs (Painter/Electrician/Steamfitter/Plumber/ Sheetmetal/Maintenance Mechanic/Carpenter/Laborer) FOR ALL JOB CLASSIFICATIONS 1. Do you have a state documented disability? yes no If yes, describe 2. Do you require an accommodation because of the disability? yes no If yes, describe 3. Do you currently have any work restrictions? yes no If yes, describe and note if these are temporary or permanent Additional information may be requested from my doctor(s)/health care provider(s) should any information be needed to clarify my ability to do the job for which I am applying. My responses on this form are true and correct to the best of my knowledge. Any misrepresentations in filling in the requested information may result in any conditional offers of employment being withdrawn, or in a decision not to hire. Employee Signature Date 7
FOR EHS USE ONLY New Employee Health Assessment Summary Check if Done: Biohazard Injuries/Exposures (Reporting mechanisms and follow up) Back Safety/Lifting Precautions/Ergonomics Worker Compensation Reporting Fitness for Duty/Return to Work Hazardous Drug Surveillance Program (TLC, Heme/Onc, Infusion Center, Pharmacy, Float, Home Health, Peds Speciality Clinic, Peds Heme/Onc, Outpatient Chemo, Environmental Services, Care Initiation Unit, Clinical Research Unit) Immunizations & Childhood Diseases Reviewed Labs Ordered PPD Given Fit for Position Further Assessment Needed Before Cleared to Work Titers PPD Urine drug screen Outside records Restrictions: None Permanent Temporary Specify Restrictions: Recommendations: None Yes Hepatitis B vaccination Resources for EAP/exercise/smoking cessation discussed (circle) Workstation ergonomic evaluation requested Other Cleared for work: Date: Not Cleared for Work: Reason: Date: Human Resources Recruitment notified via email Supervisor notified via email Supervisor Name Updated 7/1/15 EHS clinician signature 8