PRE-EMPLOYMENT HISTORY AND PHYSICAL

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MIDWESTERN UNIVERSITY OPTI - AZCOM PRE-EMPLOYMENT HISTORY AND PHYSICAL Name Department Birth Date Age Position MEDICAL HISTORY Childhood Illnesses & Immunizations Please check the following childhood diseases & immunizations you have had. Note: An official copy of your immunizations should be included with this form when returning it to Midwestern University. Yes No Yes No a. Measles e. Diphtheria/Tetnus Toxoid b. Mumps f. Polio Oral c. Chickenpox g. Rubella d. Scarlet Fever h. Hepatitis Hospitalizations Have you been hospitalized for any reason (i.e. medical trauma, injury, mental illness, chemical dependency, operation, pregnancy)? Hospital Year Reason Past Medical History Please place an (X) next to any of the following conditions that you have or had in the past. Cancer Anemia Allergies or Asthma Heart Disease Diabetes Bleeding Tendencies Tuberculosis Stroke Nervous Disorder High Blood Pressure Epilepsy Needle Sticks Back injuries Recent Immigration Recent travel outside USA Other 1

Family Medical History Please check the items that are pertinent to your family (children, brother, sister, parents, grandparents) medical history. Family Mother Father Sister (s) Living Age Deceased Cause Deceased Age Brothers (s) Children Please place an (X) next to any of the following conditions that anyone in your immediate family has ever had. Anemia High Blood Pressure Cancer Allergies or Asthma Heart Disease Stroke Diabetes Bleeding Tendencies Epilepsy Tuberculosis Nervous Disorder Other Illnesses & Medical Problems Mark the problems you have or have had during the past year. Do Not Ear & Eyes Yes No Write Here 1. Visual problems 2. Eye pain 3. Eye infection 4. Hearing problem 5. Ear infection Respiratory System 1. Nose bleeds 2. Constantly running nose 3. Wheezing 4. Coughing 5. Coughing up blood 6. Severe sweats at night Genitqurinary 1. Hernia/rupture 2. Blood while urinating 3. Pain while urinating 4. Kidney stones 5. Bladder infection 6. Painful menstrual periods 7. Vaginal discharge 8. Irregular or heavy bleeding Do Not Yes No Write Here 9. Yearly P.A.P./pelvic exams 2

10. Last menstrual period Date Cardiovascular 1. Chest pain 2. Shortness of breath 3. Palpitations 4. Ankle swelling Gastrointestinal 1. Heartburn 2. Indigestion 3. Poor appetite 4. Bloody stools 5. Constipation 6. Ulcers Musculoskeletal 1. Joint pain 2. Broken bones 3. Joint swelling 4. Chronic backache Mark the appropriate answers: Yes No Yes No 1. Frequent severe headaches Nervous condition 2. Dizzy spells Weight changes 3. Numbness or tingling Do you smoke? 4. Convultion/ fits Do you drink alcohol 5. Rashes Do you exercise Do you have any other health problems: Yes No If yes, please explain General Health: Excellent Good Poor Allergies: Do you have any allergies to medicine? Yes No If yes, please list 3

Medications: Do you take any medications or drugs regularly? Yes No If yes, please list I hereby state that the information given herein is accurate and true to the best of my knowledge and that the Medical Center employees, including Medical Center Health Services, will not be held responsible for the result of misrepresented or withheld facts. I also state that I am physically capable of performing the responsibilities related to my employment and should I be unable to do so, I understand that such limitations may affect my employment status. I hereby give my consent to a physical examination and such tests consistent with the job description and the physical requirements necessary for the position for which I am seeking employment. Date Signature of Applicant PLEASE DO NOT WRITE IN THE SECTION BELOW Blood Pressure: RA Weight Height LA Vision: OD 20/ Temperature: Oral Vision: OS 20/ Pulse: Rate Rhythm Color Vision Respiration: Rate Rhythm Rhythm General Appearance: Eyes Normal Abnormal Heart/Vessels Normal Abnormal Lid Rate Sclera Rhythm Pupils Pulses Fundl Ears Abdomen Hearing Tenderness Canal Organs Drum Masses Hernia 4

Nose Rectum Septum Hemorrhoid Mucosa Masses Normal Abnormal Normal Abnormal Sphincter Mouth/Throat GU Male Tonsils Penis Tongue Testicles Gums Prostate Teeth Chest/Lungs Gyne Sounds Labia Expansion Adnexa Breast Cervix Vagina Extremities & Back Back Normal Abnormal Extremities Normal Abnormal Muscle Strength Normal Abnormal Arms Normal Abnormal Assessment Lab Plan PPD CXR Recommend Employment Yes No Physician Signature Date Nurse Signature Date 5

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