Occupational Medicine Firefighter Baseline Evaluation
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- Adam Hardy
- 6 years ago
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1 Name: Date of Birth: Today s Date: Do you need a DOT Exam? (Circle One) YES NO OCCUPATIONAL HISTORY Current and Past Work. Please fill in past jobs since high school, starting with your current job and working backwards in time. Include second jobs and military duty. Go back as far as you can. Employer Start & End Dates (year) Job duties List any potentially hazardous exposures you may have had (metals, chemicals, dust, fumes, temperature extremes, etc.) Health issues you had during that time period (current job/ job about to begin) (in detail for current job) Continued on back of sheet (please check box if additional employers) Have you had any unprotected exposures to hazardous substances during your current or past work or health concerns related to work activities? Yes No If yes, please explain and list substances, if known: Have you had any difficulty using personal protective equipment (e.g., SCBA, other respirator, Tyvek suit)? Yes No If yes, please explain: Have you had any difficulty or do you anticipate any difficulty performing your job, participating in firefighting training simulation, or other job-related training exercises? Yes No If yes, please explain: Page 1 of 6
2 MEDICAL HISTORY Please list or describe your current or significant past medical problems, such as asthma, high blood pressure, fainting, heart problems, or diabetes. List any past surgeries: List all medications you currently take (including prescriptions, over the counter medications, and herbal products) and how long you have been taking them: List all medication allergies: List any other allergies or sensitivities: SOCIAL HISTORY Do you exercise? Yes No If Yes, please provide additional information. Type of exercise, number of days per week, duration of exercise sessions: Do you drink alcohol? Do you currently smoke or use smokeless tobacco? Did you previously smoke or use smokeless tobacco? Do you have hobbies or activities in your home that could expose you to hazardous dust, smoke, metal fumes, chemical vapors, or loud noise? What medical problems are common in your family (parents, grandparents, siblings, aunts, uncles, children)? Any heart attacks, heart problems, diabetes, or cancers in your family? How many drinks per week? (packs, cigars, tins, other) per day Greatest number was: (packs, cigars, tins, other) per day Smoked for years. Quit date: Potential home exposures: Family member, name of illness, age when illness developed: Page 2 of 6
3 Do you have or have you ever had any of the following conditions or symptoms? Yes No Yes No 6.3 Head and Neck Chronic bronchitis Skull, head or face injury Emphysema Thoracic outlet syndrome Pneumonia Neck cysts or draining wounds Tuberculosis Limited movement of the neck Silicosis 6.4 Eyes and Vision Pneumothorax (collapsed lung) Glasses or contact lenses Lung cancer Hard contact lenses Broken ribs Trouble seeing colors Chest injuries or surgeries Retina or optic nerves problems Cystic fibrosis Surgeries, including lasik or other vision Asthma correction surgery Loss of vision in either eye Shortness of breath Shortness of breath when walking fast on level ground or walking up a slight hill or 6.5 Ears and Hearing incline Shortness of breath when walking with other people at an ordinary pace on level Balance problems or dizziness ground Needing to stop for breath when walking Hearing loss or need for a hearing aid at your own pace on level ground Shortness of breath when washing or Ears or ear canal injury dressing yourself Shortness of breath that interferes with your Tumors of the ears or ear canals job Coughing that produces phlegm (thick Ear infections sputum) Surgeries on the ear or ear canal Coughing that wakes you early in am Coughing that occurs mostly when you Ringing in the ears are lying down Rupture of the ear drum Coughing up blood in the last month 6.6 Dental Wheezing Jaw, teeth or gum problems Wheezing that interferes with your job Braces or orthodontic appliances Chest pain when you breathe deeply 6.7 Nose, Oropharynx, Trachea, Esophagus, and Larynx Other symptoms that may be related to lung problems Nose, mouth, or neck trauma 6.9 Heart and Vascular System Voice or speech difficulty Heart attack Nasal allergies or drainage Stroke Nose bleeds Angina (chest pain) Sinus infections or headaches Heart failure Trouble smelling odors Swelling in legs/feet (not from walking) Nose or airway polyps or masses Heart arrhythmia (heart beating irregularly) 6.8 Lungs and Chest Wall High blood pressure Asbestosis Heart surgeries Sleep apnea Defibrillator or pacemaker Page 3 of 6
4 Infections of the heart or surrounding tissue Enlarged heart Other heart problem Blood clots Abdominal or thoracic aneurysm Thrombophlebitis or varicose veins Raynaud s phenomenon or other vasospastic disorders Surgery on any blood vessel Narrowing of the carotid arteries Other blood vessel problems Chest pain or tightness Chest pain or tightness during physical activity Chest pain or tightness that interferes with your job Heart skipping or missing a beat Heartburn or indigestion that is not related to eating Pain, burning, or numbness in legs with activity & goes away with rest Swelling of any body part Feeling dizzy or lightheaded with standing up Other symptoms related to heart or circulation problems 6.10 Abdominal Organs and Gastrointestinal System Inguinal umbilical or femoral hernia Gallbladder problems Bleeding of the GI tract Hepatitis Inflammatory bowel disease Irritable bowel syndrome Intestinal obstruction Pancreatitis or pancreas problem Diverticulitis Abdominal or GI surgery Ulcers Cirrhosis of the liver Spleen problems or removal Repetitive vomiting Yes No Yes No 6.11 Reproductive System Females: Are you currently pregnant Severe pain with menstrual cycles Endometriosis or ovarian cysts Males: Lumps or masses in or near the testicles Chronic pain in the testicles, groin or scrotum 6.12 Urinary System Kidney failure Kidney or bladder disease 6.13 Spine and Axial Skeleton Back injury Back pain lasting more than 1 week Weakness in arms, hands, legs, or feet Limited motion in arms or legs Pain or stiffness leaning forward or backward at the waist Difficulty fully moving your head up or down Difficulty fully moving your head side to side Knee bending difficulty Squatting difficulty Surgery on back, spine, or neck Scoliosis or deformities of the spine Problems climbing a flight of stairs or a ladder carrying >25 lbs Other muscle or skeletal problems 6.14 Extremities Hardware such as metal plates or rods supporting a bone fracture Artificial joint such as hip or knee Missing fingers or limbs Healing bone grafts Limited mobility in either shoulder Dislocated shoulders or shoulder surgery Limited mobility in any limb or joint Knee surgery or repair Arthritis Page 4 of 6
5 Yes No Yes No Fractured bone that did not properly heal Enlarged spleen Osteomyelitis (bone infection) Low white blood cell count 6.15 Neurological Disorders Blood clots or need for blood thinners Seizures (fits) or Epilepsy Too many blood cells (polycythemia) Balance, walking or movement problems 6.18 Endocrine and Metabolic Passing out while at rest or with activity Diabetes Tremors Thyroid problems Muscular weakness Disease of the pituitary, adrenal, or parathyroid glands Paralysis of any limb Other hormone or nutrition problem Memory problems 6.19 Systemic Diseases and Miscellaneous Migraine or other chronic headaches Lupus, scleroderma, rheumatoid arthritis, or dermatomyositis Altered sensation or numbness Burn injury with ongoing problems Cerebral aneurysm Heat stress or other heat injury Multiple sclerosis 6.20 Tumors and Malignancies Muscular dystrophy Tumor, malignancy, or cancer Head injury 6.21 Psychiatric Conditions Bleeding in head or brain Depression or other mood disorders 6.16 Skin Anxiety Skin cancer Alcoholism Rashes Other substance abuse Skin grafts Other psychiatric condition Other skin problem 6.22 Chemicals, Drugs, and Medications 6.17 Blood Pain medications Blood transfusions Sleep medications Sickle cell disease Steroids Clotting or bleeding disorders Blood thinners Anemia (low red blood cell count) Beta blockers or clonidine Yes No Have you worn a respirator? If you've used a respirator, have you ever had any of the following problems while using a respirator? a. Eye irritation b. Skin allergies or rashes c. Anxiety d. General weakness or fatigue e. Trouble breathing f. Any other problem that interferes with your use of a respirator What type of respirator will you use? a. Disposable respirator (filter-mask, non- cartridge type only). b. Other type (for example, half- or full-face piece type, powered-air purifying, suppliedair, self-contained breathing apparatus (SCBA)). Describe the work you will be doing while you are using your respirator(s), including any special or hazardous conditions you might encounter when you're using your respirator(s) (for example, confined spaces, lifethreatening gases): Page 5 of 6
6 Please provide information about your yes responses to the medical questions above. The above medical history is accurate to the best of my knowledge. Signature Date Physician Section Comments: I have reviewed and discussed the medical information provided in this questionnaire with this employee. Signature Date Page 6 of 6
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Caspian Acupuncture -- Health History Form Anita Tayyebi EAMP, LAc. 652 SW 150 th St Burien WA 98166
Frist Name Last: Date Phone (H) (C) (W) E-mail Address City State Zip Age DOB Place of Birth _ Marital/Partnership Status Preferred Gender Pronoun _ Profession Family Physician Telephone # Referred By
Please describe, in detail, when the symptoms began:
161 East Mallard Drive, Suite 130, Boise, ID 83706 (208) 947-0100 New Patient Intake Patient Name: Primary Care Physician: Date: Email address: How did you hear about AVT (mark all that apply) Online On
Columbus Oncology and Hematology Associates 810 Jasonway Ave. Columbus, OH 43214, Ph: , Fax:
Columbus Oncology and Hematology Associates 810 Jasonway Ave. Columbus, OH 43214, www.coainc.cc Ph: 614.442.3130, Fax: 614.442.3145 Name (Last, First, Middle) Birth Date Age Social Security # Appointment
LECOM Health Ophthalmology
Patient Name: Date of Birth: New Patient Questionnaire Your answers will be used by your healthcare provider get an accurate history of your medical conditions and ocular concerns. If you are uncomfortable
Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):
Name: DOB: Date of Appointment: Please list all doctors you currently see (Primary Care Physician and Specialists i.e. Cardiologist): Please list any medications you currently taking along with dosage
Occupation Agency Code Work Location Work Supervisor Duty tel. #
PRIVACY ACT STATEMENT: This information is subject to the Privacy Act of 1974 (5 U.S.C. Section 552a). This information may be provided to appropriate Government agencies when relevant to civil, criminal
Interventional Pain Medicine. P. Tennent Slack, M.D. Dr. Greg Jackson, M.D. Ben Fleming, PA-C
Interventional Pain Medicine P. Tennent Slack, M.D. Dr. Greg Jackson, M.D. Ben Fleming, PA-C Gainesville Braselton Medical Park 1, Suite 300 Medical Plaza B, Suite 402 1315 Jesse Jewell Parkway 1404 River
New Patient Questionnaire
New Patient Questionnaire Name: Primary Care Physician: Date of Birth: / / Home Phone: ( ) Cell Phone: ( ) Why are you seeing a cardiologist? (please answer in detail) Have you ever seen a cardiologist
MALE MEDICAL HISTORY FORM (please circle answers/complete blanks) rev 2/2014
MALE MEDICAL HISTORY FORM (please circle answers/complete blanks) rev 2/2014 Name: Date of Birth: Today s Date: Where did you get healthcare before? May we request records? Y N (requires signed release)
New Pulmonary Patient Questionnaire. Name Age Date. General Medical History
New Pulmonary Patient Questionnaire Name Age Date General Medical History 1 John S. Kim, M.D., Diplomate ABSM Lawrence A. Lynn, D.O., FCCP 1. Please list any surgeries you have had and their approximate
PATIENT HEALTH HISTORY
Name DOB Sex Age Date MR# PLACE CHARGE TICKET LABEL IN THE DASHED SPACE OR COMPLETE THE ABOVE: PLEASE ANSWER EACH QUESTION AS CORRECTLY AS YOU CAN BY PLACING AN "X" IN APPROPRIATE BOX What is the reason
The Advanced Spine Center Jason E. Lowenstein, MD Jamie L. DiGraziano, PA-C
The Advanced Spine Center Jason E. Lowenstein, MD Jamie L. DiGraziano, PA-C ADULT SPINE HISTORY For Office Use Only: HR: BP: / Name of Patient: Date: Date of Birth: Age: Height: ft in Weight: lbs Form
*542686* How severe is the problem? mild moderate severe Is it getting better or worse? Better Worse Same over the last hours days weeks months
*542686* Referring Doctor Name: Specialty: City: State: Primary Doctor Name: Specialty: City: State: Instructions: On the body drawing below, please show where you feel pain at this time. Please mark only
MONTEFIORE MEDICAL CENTER TRANSPLANT PROGRAM LIVING DONOR EVALUATION FORM History Questionnaire
MONTEFIORE MEDICAL CENTER TRANSPLANT PROGRAM LIVING DONOR EVALUATION FORM History Questionnaire Donor s Name: Today s Date: Social Security #: Date of Birth Age Sex Address: Telephone #: (home) (work)