PERSONAL MEDICAL HISTORY - Cape Fear Valley
PERSONAL MEDICAL HISTORY
INSTRUCTIONS TO THE APPLICANT
The completion of this questionnaire and the subsequent medical examination and test/vaccinations are required for you to enter employment with Cape Fear Valley Health System. Signature of the Consent to Examination authorizes us to test you for certain infectious diseases and for possible illegal drug usage.
Name: __________________________________________________________Date:____________________________ Date of Birth: ________________________ Sex: ______________________ Race: ____________________________ Department applied for ____________________________________Position_________________________________ Personal Physician Name ___________________________________Phone number ___________________________
A. Have you ever had or now have any of the following: Check below:
Yes No
Yes No
Yes No
Heart trouble
Pulmonary disease
Swelling of feet or ankles
High blood pressure
Rheumatic fever
Any amputations
Heart disease
Shortness of breath
Hearing loss
Chest pain or pressure
Pneumonia
Cataracts
Varicose veins
Tuberculosis
Wear glasses or contacts
Blood disorder Diabetes
Frequent colds Frequent sore throat
Claustrophobia (fear of closed places) Anemia
Sugar in the urine
Chronic persistent cough
Venereal disease or AIDS
Blood in the urine
Bronchitis
Frequent ear infections
Thyroid disorder
Coughing/spitting up blood
Loss of sight (either eye)
Glandular disorder
Hernia
Skin rash or infection
Kidney problems Epilepsy
Heart murmur Frequent headaches
Other Cardiovascular or heart symptoms
Convulsions
Migraine headaches
Fainting or dizzy spells
Bladder disorder
Blackouts
Prostate disorder
Asthma
Reproductive organs disorder
Hay fever
Womb disorder
Allergy problems
Ovary disorder
Emphysema
Sex sterilization operation
Lung disorder
Breast problems
Respiratory problems
Back injury problems or pain
Carpal Tunnel
Neck injury, problems or pain
Sinus problems
Back disease
Spine disease
Muscle disorder
Arthritis
Cancer
Bone or joint deformity
Tumor
Cyst
Abnormal growth
Ulcer problems
Mental or nervous problems
Colitis disorder
Digestive system problems
Gastrointestinal disorder
Foot problems
Revised: 03/21/2017
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B. Have you ever : (check the box) Yes No
1. Had a positive tuberculin test? 2. Had a blood test for hepatitis? 3. Been denied insurance coverage? 4. Habitually taken drugs and/or alcohol? 5. Had or been advised to have a surgical operation in the last 10 years? 6. Consulted a physician, chiropractor, osteopath, psychiatrist, psychologist, or other Medical Practitioner in the past 5 years? 7. Had any injury, disease, disorder, condition, physical or mental impairment not covered by the question in A or
B? 8. Tested positive for HIV or AIDS?
Employees who know that they are infected with HIV and/or Hepatitis B and perform or assist in surgery, dental procedures, or vaginal deliveries are to report themselves to the Chief, Communicable Disease Control Section, North Carolina Department of Environmental , Health, and Natural Resources, P. O. Box 27887, Raleigh, NC 27611-7687. This is required by law and is solely the employee's responsibility. Faculty and employers are responsible for communicating this information to their students, employees and independent contractors.
Employees with an impaired immune system will be counseled about the potential risk associated with taking care of patients with any transmissible infection.
HIV antibody testing is available to new employees if the EH provider deem it necessary due to history or Physical.
For each "Yes" answer to questions A or B above, please explain below:
CONDITION
DATE
TREATMENT+RESULTS
C. Please answer the questions below concerning your current health status.
1. Are you taking or should you be taking any medications now?
Yes
No
If so, what are they and what are the reasons for taking them?
___________________________________________________________________________________________
_________________________________________________________________________________________
2. Are you receiving medical treatment at this time?
Yes No
If so, give reason: ________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
3. Are you allergic to any drugs, medications or substances?
Yes No
If yes, list all of them and specify type of reaction such as itching, swelling, wheezing, rash, etc.
___________________________________________________________________________________________
_________________________________________________________________________________________
Revised: 03/21/2017
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4. Have you, in the past 2 years, smoked or chewed tobacco products? Yes No If yes, how long (have)/(did) you do so?____________________________________
5. Has your weight changed (by 10 pounds or more) in the last two years?
Increased
Decreased No change
D. The following questions concern work related injury or illness
1. Have you ever been injured on the job? If yes, please answer the following questions:
Yes No
a. Approximate date of injury______________________________________
b. Part of body that was injured ___________________________________
c. Who was your employer? ______________________________________
d. Treating physician or hospital ___________________________________
e. Have you received any permanent disability rating?
Yes No
If yes, please describe:
_________________________________________________________________________________
___________________________________________________________________________________
_______________________________________________________________________________
f. Have you ever been given physical restrictions by a physician? Yes No If yes, please describe: ___________________________________________________________
_________________________________________________________________________________
g. How much time did you miss from work? _________________________________________
1. Have you ever had any other diseases or illnesses attributable to your work? Yes No If yes, please describe: ________________________________________________________________
E. Certification I hereby certify that the foregoing statement and answers:
a. Are complete and true to the best of my knowledge and belief; b. Are correctly and fully recorded; and c. Omit no material circumstances or information concerning the past or present state of my health
or medical history. d. I understand that failing to complete this honestly and accurately and without any material
omission is grounds for discharge.
Applicant Signature _________________________________Date_________________________
Print Name: ________________________________________
Witness: __________________________________________Date/Time: ___________________
Revised: 03/21/2017
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F. Consent to Examination
I, _______________________________________________, consent to undergoing pre-employment medical examinations, blood and/or urine collection samples as requested by Cape Fear Valley Health System. The examination and tests are required before I can become an employee or to continue my employment at Cape Fear Valley Health System.
I understand that tests are for the purpose of determining the presence of alcohol and drugs, if any, the existence of any diseases or infections, and to determine if I am able to perform the essential functions of the position for which I am being considered.
I furthermore authorize the release of any and all medical information obtained during examination and testing procedures to the Manager of Employee Health Services of Cape Fear Valley Health System as deemed appropriate.
I understand that a positive result for the alcohol and/or drugs may result in my being ineligible for employment.
I further understand that my refusal to cooperate fully with this Pre-Employment Testing Program results in my being ineligible for employment.
I understand and agree that any employment related work for Cape Fear Valley Health System, prior to examination/testing date(s), is contingent upon my successful completion of this program.
_______________________________________________ Applicant Signature
_______________________________________________ Witness
____________________________ Date
____________________________ Date/Time
Revised: 03/21/2017
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Respiratory Questionnaire
Employee: Can you read? Yes No Your employer must allow you to answer this questionnaire during normal working hours, or at a time and place that is convenient to you. To maintain your confidentiality, your employer or supervisor must not look at or review your answers, and your employer must tell you how to deliver or send this questionnaire to the health care professional who will review it.
Part A. Section 1. (Mandatory) Every employee who has been or may be selected to use any type of respirator must provide the following information (please print).
1. Date:
2. Name:
3. Age:
4. Sex: Male / Female 5. Height: Ft.
In.
6. Weight
7. Job Title:
8. Home or Cell Phone:
9. Best time to reach you:
10. Has your employer told you how to contact the health care professional who will review this questionnaire?
Yes No
(Employee Health Nurse, CFVHS, 910-615-3172, M-F, 0700-1700)
11. Have you worn a respirator (check one): If "yes" what type(s):
Yes No
Part A. Section 2. (Mandatory)
Questions every employee who has been or may be selected to use any type of respirator must answer 1 through 9 below (please check "Yes" or "No").
1. Do you currently smoke tobacco, or have you smoked tobacco in the past month? Yes No
2. Have you ever had any of the following conditions? Yes No
a. Seizures (fits)
d. Diabetes (sugar disease)
1. Allergic reactions that interfere with your breathing
c. Trouble smelling odors
e. Claustrophobia (fear of closed-in places)
Yes No
3. Have you ever had any of the following pulmonary or lung problems?
Yes No
Yes No
a. Asbestosis
e. Asthma
i. Chronic bronchitis
b. Emphysema
f. Pneumonia
j. Tuberculosis
c. Silicosis
g. Pneumothorax
k. Lung cancer
(collapsed lung)
d. Broken ribs
h. Any chest njuries
l. Any other lung problem
or surgeries
that you've been told about
Yes No
Revised: 03/21/2017
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Print Name: ____________________________
4. Do you currently have any of the following symptoms of pulmonary or lung illness? Yes No
a. Shortness of breath b. Shortness of breath when walking fast on level ground or walking up a slight hill or incline c. Shortness of breath when walking with other people at an ordinary pace on level ground d. Have to stop for breath when walking at your own pace on level ground e. Shortness of breath when washing or dressing yourself f. Shortness of breath that interferes with your job g. Coughing that produces phlegm (thick sputum) h. Coughing that wakes you early in the morning i. Coughing that occurs mostly when you are lying down j. Coughing up blood in the last month k. Wheezing l. Wheezing that interferes with your job m. Chest pain when you breathe deeply n. Any other symptoms that you think may be related to lung problems
5. Have you ever had any of the following cardiovascular or heart problems?
Yes No
Yes No
a. Heart attack
e. Swelling in your legs or feet (not caused by
walking)
b. Stroke
f. Heart arrhythmia
c. Angina
g. High blood pressure
d. Heart failure
h. Any other heart problem that you've been told about
6. Have you ever had any of the following cardiovascular or heart symptoms? Yes No
a. Frequent pain or tightness in your chest b. Pain or tightness in your chest during physical activity c. Pain or tightness in your chest that interferes with your job d. In the past two years, have you noticed your heart skipping or missing a beat? e. Heartburn or indigestion that is not related to eating f. Any other symptoms that you think may be related to heart or circulation problems
7. Do you currently take medication for any of the following problems?
Yes No
a. Breathing or lung problems
c. Blood pressure
b. Heart trouble
d. Seizures (fits)
Yes No
8. If you've used a respirator, have you ever had any of the following problems? (If you've never used a
respirator, check here and go to question 9).
Yes No
Yes No
a. Eye irritation
d. Skin allergies or rashes
b. Anxiety
e. General weakness or fatigue
c. Any other problem that interferes with your use of a respirator
9. Would you like to talk to the health care professional who will review this questionnaire about your
answers to this questionnaire?
Yes No
Revised: 03/21/2017
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Print name:
Questions 10 to 15 below must be answered by every employee who has been or may be selected to use either a full-face piece respirator or a self-contained breathing apparatus (SCBA). For employees who have been or may be selected to use other type of respirators, answering these questions is voluntary.
10. Have you ever lost vision in either eye (temporarily or permanently)?
Yes No
11. Do you currently have any of the following vision problems?
Yes No
a. Wear contact lenses
c. Wear glasses
b. Color blind
d. Any other eye or vision problem
Yes No
12. Have you ever had an injury to your ears, including broken eardrum?
Yes No
13. Do you currently have any of the following hearing problems?
a. Difficulty hearing b. Wear a hearing aid c. Any other hearing or ear problem
Yes No
14. Have you ever had a back injury?
Yes No
15. Do you currently have any of the following musculoskeletal problems?
a. Weakness in any of your arms, hands, legs, or feet b. Back pain c. Difficulty fully moving you arms and legs d. Pain or stiffness when you lean forward or backward at the waist e. Difficulty fully moving your head up or down f. Difficulty fully moving your head side to side g. Difficulty bending at your knees h. Difficulty squatting to the ground i. Climbing a flight of stairs or a ladder carrying more than 25 lbs. j. Any other muscle or skeletal problem that interferes with using a respirator
Yes No
Print Name: _______________________________________Date: ______________________________ Signature: ________________________________________ Dept: ______________________________ Employee #: ______________________________________ Date of Birth: _______________________ Manager's Name: __________________________________
Do not write below, clinic use only
Initial as appropriate
Cleared for Fit Test Port-a Count Only Smoke Only
Any approved method Unable to clear for Fit Testing Hood Only
Revised: 03/21/2017
7|Page
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