Name: Date of Birth: SS#: Department/Title: Date of Physical Exam: Post Offer Physical Examination is: Complete Pending Medical Clearance

Transcription

1 Name: of Birth: SS#: Department/Title: of Physical Exam: Post Offer Physical Examination is: Complete Pending Medical Clearance Signature of Physician/Nurse Practitioner completing physical exam of exam Section to be completed and faxed to Human Resources once PPD, Drug Screen, and Physical Exam are completed Qualified Failed Signature of Physician/Nurse Practitioner Please fax completed form to Human

2 MEMORIAL HEALTH SYSTEMS PRE-PLACEMENT PHYSICAL EXAM Name: of Birth: : Department: Job Title: Facility: Medical History Yes No Unsure Details Have you received any compensation awards, disability insurance or pension because of illness or injury? Have you had any surgery or hospitalization? s? Reasons? Any eye or ear conditions? Have you ever been told you have a heart or blood vessel disease? Have you or any blood relative ever had a heart attack? Have you ever had an abnormal electrocardiogram (EKG)? Have you ever had angina, thumping or racing of your heart beat? Have you ever had any heart murmurs? Do you get any regular vigorous exercise? Have you ever been told you had high blood pressure? Do you ever have shortness of breath? Do you have any difficulty using respirators? Have you ever had asthma or any lung or chest disorder or surgery? Have you ever had a hernia? Location? Are you pregnant? Have you had bone or joint disease, factures or dislocations? Have you had back or neck injuries, pain or other disorders? Have you ever had a skin reaction to any substances or any persistent or recurrent skin conditions? Have you ever had a seizure, convulsion, repeated fainting or dizzy spells? Have you ever had migraines, recurrent headaches or head injury? Have you ever had neuralgia, neuritis, nerve disorders or injury? Have you ever had a psychiatric or emotional illness or nervous disorder? Have you ever had or do you have diabetes or excessive thirst? Have you ever had abdominal disorders such as stomach or intestinal spasms, ulcer, colitis, diverticulitis, pancreatitis or other disorder? History of Diseases: Immunization Records Provided Yes No Have you ever had: Yes No Unsure Have you ever had: Yes No Unsure Measles Scarlet Fever Typhoid Fever Tuberculosis Dysentery Mumps Whooping Cough Chicken Pox Diphtheria

3 Name: of Birth: Address: City: State,Zip: Home Phone: Cell Phone: Gender: Vitals: BP R Arm / BP L Arm / Pulse Temp Wt Ht Allergies: Medications: Recent Medical Treatment: Surgeries: Major Trauma: Medical Conditions/Diseases: Social History: Have you ever smoked cigarettes, cigars, pipe, chewed tobacco or rubbed snuff? Yes No Do you currently smoke or chew tobacco or rub snuff? Yes No If yes, how much per day? Have been advised to quit? Yes No Do you drink alcohol? Yes No If yes, how often? I give my permission to release any and all information both written and verbal, regarding my medical conditions or files to MHS or its designee. I certify that all my responses are true to the best of my knowledge. I understand that any falsification of information may result in disciplinary action, up to and including termination of my employement with MHS. Print Name Signature of Employee

4 Name: of Birth: Physical Exam: General Lungs Respiratory Well Nourished Clear A/P Easy/Unlabored Obese Wheezing Dyspenic Pale Rhonchi Labored with Exertion Pink Labored NAD Heart Abdomen Spine-Flexion Regular Rate & Rhythm Soft BS x4 Normal Murmur Organmegly Abnormal Musculoskeletal-Gait Normal Abnormal Inguinal Hernia (Male) Normal Abnormal Vision: Far Uncorrected Far Corrected Near Uncorrected Near Corrected Both 20/ Both 20/ Both 20/ Both 20/ Right 20/ Right 20/ Right 20/ Right 20/ Left 20/ Left 20/ Left 20/ Left 20/ Color Vision Binocular Vision Corrected Used Horizontal Peripheral Vision Basic Yes Wears Glasses Right (degrees max 85) Normal No Wears Contacts Left (degrees max 85) Abnormal Wears Reading Glasses Back Requirements: Lift Instructions Reviewed Yes No Comments: Lift Performed Yes No Back Pamphlet Given Yes No Flex & Extension Exam Yes No Signature of Medical Examiner Exam Completed

5 Name: of Birth: Employee Latex Allergy Screening Tool Important caution: This tool is not intended to be all-inclusive. Individuals who are uncertain whether they are or may have sensitivities to natural latex should consult their physician. Have you ever had a reaction to latex devices? Yes No If yes, describe the reaction and under what circumstances did it occur? Have you ever been told by a doctor that you have an allergy to any latex product? Yes No If yes, to what specifically did the doctor say you were allergic? Do you have any congenital abnormalities (i.e. spina bifida, myeloma)? Yes No Have you had a reaction to the following personal sources of latex? Balloons Yes No Latex birth control Yes No Rubber gloves Yes No Dental Retainer Yes No Hot water bottles Yes No Erasers Yes No Rubber bands, balls Yes No Face masks Yes No Foam pillows Yes No ACE bandages Yes No Baby bottle nipples Yes No Cuffs, elastic Yes No Pacifiers, teething Yes No Ostomy bags Yes No Belts, Bras Yes No Shoewear Yes No Rubber grips Yes No Other Yes No After handling latex products, have you experienced: Difficulty breathing Yes No Redness Yes No Chapped/cracked skin Yes No Swelling Yes No Runny eyes Yes No Hives Yes No Itching hands/eyes Yes No other Yes No Do you have a history of: Contact dermatitis Yes No Eczema Yes No Asthma Yes No Autoimmune disease Yes No Hay fever Yes No (i.e. Lupus, etc) Do you have any food allergies? Yes No Are you allergic to any of the following: Bananas Yes No Kiwis Yes No Tomatoes Yes No Avocados Yes No Chestnuts Yes No Papaya Yes No Potatoes Yes No Peaches Yes No Other Yes No If yes, to any above foods, describe your reaction Have you had any previous surgeries? Yes No If yes, how many before the age of one? Have you had any extensive dental work? Yes No Employee Signature Signature of Employee Health Nurse Latex allergy policy given and reviewed. Signature

6 Name: of Birth: New Employee TB Screening and Consent Form Have you ever had TB or been exposed to TB? Have you ever had a reaction to TB skin test? Have you been treated for TB infection or disease? Are you foreign-born? Have you had BCG live vaccine? Have you had a live vaccine in the past 4 weeks (i.e. MMR, Chickenpox, other)? Are you taking medicines that affect immunity (i.e. steroids)? Do you have a health condition that may interfere with TB testing? Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No If yes to any of the above, please explain: of last TB test, if known: I consent to administration of the tuberculosis skin test. I do not consent to TB skin testing. Please explain: If you are HIV Positive please notify the Employee Health Director before the administration of the TB skin test. Employee Signature For Office Use Tubersol Sanoft Pasteur Given Aplisol JHP Pharmaceuticals LLC Arm Lot # Given By Tuberculin purified protein derivative 5 TU (.1 ml) intradermal Read Result in mm Read By R/L If your 1st PPD is read somewhere other than MOHP, please fax form to (740) immediately. Tubersol Sanoft Pasteur Given Aplisol JHP Pharmaceuticals LLC Arm Lot # Given By Tuberculin purified protein derivative 5 TU (.1 ml) intradermal Read Result in mm R/L If your 2nd PPD is read somewhere other than Employee Health, please fax form to: MMH Employees (740) Selby Employees (740) Attn Anna Smith Read By

7 Name: of Birth: Hepatitis B Vaccination Evaluation Marietta Memorial Health Systems provides vaccination against Hepatitis B for all employees with jobs which require tasks that may involve exposure to blood, body fluids, or tissues, or that have the potential for spills or splashes. Vaccination need not be made available to employees who have previously completed the vaccination series, if antibody testing reveals immunity, or if the vaccine is contraindicated for medical reasons. If you are currently employed in a job which does not involve exposure to blood but at a later date you transfer to a position that does have the potential, please contact Employee Health to obtain vaccinations. Have you completed the Hepatitis B vaccination series? Yes No Vaccination s #1 #2 #3 Has antibody testing revealed immunity? Yes No Where / When / Result Is there a medical reason you should not be vaccinated? Yes No Please explain: Employee Signature For Office Use The Hepatitis B vaccination is indicated for the above employee. The Hepatitis B vaccination is not indicated because: Vaccination in not offered for job position. Documentation of previous Hepatitis B vaccination is on file. Antibody testing reveals immunity. There is a medical contraindication to vaccination. We do not have documentation of proof of immunity to Hepatitis B. If you are exposed to blood or body fluids, please advise the healthcare provider treating you so you will receive appropriate care. Comments: Employee Health Professional s Signature copy made to be given to employee Initials

8 Name: of Birth: Hepatitis B Vaccine Consent Marietta Memorial Health Systems makes Hepatitis B vaccination available to any employee with a job that involves risk of occupational exposure to bloodborne diseases. Vaccination is available at no cost, during normal working hours. The employee is responsible to contact Employee Health to arrange time for vaccination. Testing for immunity is recommended one to two months after completing the vaccination series. I consent to Hepatitis B vaccination. Signature Department Site Dose Brand/Lot# VIS Given By Hepatitis B immunity test date: Result: SIGN BELOW ONLY IF YOU DO NOT WANT HEPATITIS B VACCINATION I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring Hepatitis B Virus (HBV) infection. I have been given the opportunity to be vaccinated with Hepatitis B vaccine, at no charge to myself. However, I decline Hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with Hepatitis B vaccine, I can receive the vaccination series at no charge to me. Employee Signature Revised/Reviewed: Feb 88/Apr 01/Jul 02/Aug 03/Jun 04/Jan 05/Dec 05/Jun 07/Feb 09/Feb 10/Jun 10/Dec 10/Jul 12/Nov 12