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

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