Must be completed by Temple University Hospital Department of Occupational Health

Graduate Medical Education 3509 North Broad Street Tel (215) 707-6400 2 nd Floor, Boyer Pavilion Fax (215) 707-4721 Philadelphia, PA 19140-5189 April 2011 To: From: Re: All Prospective House Staff Kristine C. Schade, RN,OHN, Director, Employee/Occupational Health Susan Coull, MBA, DIO, Director, Graduate Medical Education Pre-employment (post job offer) medical examinations It is the policy of Temple University Health System that as a condition of employment, a pre-employment (post job offer) medical examination of all prospective employees must be conducted, to ensure that the individuals are medically able to perform their assigned duties. This policy applies to ALL Temple University Health System employees. All physical examinations must be completed and documented before your respective start dates (6/10/11 or 7/1/11), before you are eligible to begin work and be approved for payroll. The pre-employment medical examination consists of the following: Drug Screen: Must be completed by Temple University Hospital Department of Occupational Health 2step PPD (tuberculin skin test) for Completion of CDC annual medical those with a history of negative review tuberculosis questionnaire for PPD results those with PPD+ history Blood testing will also be accepted Chest x-ray (or documentation of x-ray such as Quantiferon or T-Spot performed within the past 5 years) Color vision test (visual testing for Basic vision test color deficiency) Hepatitis B vaccine (3 shot series) Or sign a declination form Blood work (titers) rubella measles mumps varicella hepatitis-b Proof of Pertussis booster is highly recommended Medical exam by a licensed medical provider Completion of an employee information sheet & medical history evaluation report You have two options to accomplish completion of this requirement: 1. You can call the Occupational Health Services department of Temple University Hospital and schedule a time to have your pre-employment physical performed. Physical examinations are conducted Mondays through Thursdays from 8 AM to 4 PM and Fridays from 8AM to 12Noon. All physical examinations must be completed and documented before your respective start dates (6/10/11 or 7/1/11). 2. If you choose, you can have the physical examination performed by your personal physician and present the documentation to our office prior to your respective start date (6/10/11 or 7/1/11). Copies of all necessary forms to be completed by your personal physician are attached. You still must make an appointment with Occupational Health to complete your urine drug screen and breath alcohol tests. These tests must be completed at

TUH. All physical examinations must be completed and documented before your respective start dates (6/10/11 or 7/1/11). *Any fees associated with your decision to have the physical examination done by your physician will be your responsibility. Please print and complete the attached forms. If you have your physical done by your personal physician, please have him or her use the attached physical form. You must have the Respiratory Fit forms with you at orientation. Your fit test will be performed during orientation. Once again, all physical examinations must be completed and documented before you prospective start dates (6/10/11 or 7/1/11). When calling the Occupational Health Services Department, please identify yourself as a prospective 2011 resident and which option you have chosen so that appropriate scheduling is performed. You will need to provide your social security number and date of birth in order to schedule an appointment. To schedule an appointment, ask any questions or present special concerns, please contact the Occupational Health Services Department at 215-707-4455. Copies of documentation completed by your medical provider can be faxed to (215) 707-5751 to the attention of the Employee Health Nurse. You may also mail the information to: Temple University Hospital Occupational Health Services Attention: Employee Health Nurse 3401 North Broad Street Rock Pavilion Basement Philadelphia, PA 19140 We look forward to your coming to Temple and extend best wishes to you in your residency.

HISTORY & PHYSICAL EVALUATION Pre-employment Annual Update NAME: LAST,FIRST TODAY S DATE CURRENT ADDRESS: CITY, STATE, ZIP SEX DATE OF BIRTH HOME TELEPHONE SOCIAL SECURITY # FAMILY PHYSICIAN NAME PHYSICIAN TELEPHONE IN CASE OF EMERGENCY CONTACT (NAME, ADDRESS, PHONE) PREVIOUS TEMPLE UNIVERSITY STUDENT? YES NO PREVIOUS TEMPLE HOSPITAL EMPLOYEE? YES NO IF YES, GIVE PROGRAM AND YEAR OF GRADUATION OR DEPARTMENT DO YOU HAVE ALLERGIES TO MEDICATIONS? YES NO IF YES, PLEASE LIST (INCLUDE PENICILLIN, SULFA DRUGS, TETRACYCLINE, ETC) ARE YOU TAKING ANY MEDICATIONS NOW? YES NO IF YES, PLEASE LIST (INCLUDE ANTIBIOTICS, BIRTH CONTROL, ETC.) DO YOU HAVE ALLERGIES TO ANY FOODS? YES NO IF YES, PLEASE LIST HAVE YOU EVER BEEN TOLD BY A DOCTOR THAT YOU HAVE AN ALLERGY TO ANY LATEX PRODUCT? YES NO IF YES, HOW WERE YOU DIAGNOSED? DON T KNOW SKIN PRICK TEST RAST TEST WEAR TEST PATCH TEST HAVE YOU EVER HAD A REACTION ATTRIBUTED TO LATEX? YES NO IF YES, PLEASE DESCRIBE ARE YOU ALLERGIC TO ANY OF THE FOLLOWING? YES NO YES NO YES NO BANANA RUBBER BANDS RUBBER CEMENT AVOCADO ADHESIVE TAPE SUSPENDERS POTATOES ACE BANDAGES TEETHING RINGS KIWI BITE BLOCK CONDOMS CHESTNUTS BANDAGES ERASERS MILK BELTS FACE MASKS PEACHES BRASSIERES FOAM PILLOWS TOMATOES GARDEN HOSES GRIPS PAPAYA LATEX CUFFS OSTOMY BAGS PASSION FRUIT PACIFIERS DENTAL MASKS BALLOONS SHOES WEATHER STRIPPING HOT WATER BOTTLES CARPET BACKING ELASTIC RUBBER BALLS CLOTHING UNDERGARMENTS IV TUBING RUBBER GLOVES 1

HISTORY & PHYSICAL EVALUATION NAME (LAST, FIRST): DATE: DEPARTMENT: MEDICAL HISTORY: DO YOU HAVE OR HAVE YOU EVER HAD ANY OF THE PROBLEMS LISTED BELOW? (PLEASE CHECK) ASTHMA PALPITATIONS WHEEZING LEG SWELLING CHRONIC COUGH PHLEBITIS COUGHING OF BLOOD KIDNEY STONES HEPATITIS SHORTNESS OF BREATH BLOOD IN URINE JAUNDICE PNEUMONIA URINARY TRACT INFECTION EMPHYSEMA DIFFICULTY WITH URINATION TUBERCULOSIS STROKE HIGH BLOOD PRESSURE PERSISTENT DIZZINESS RHEUMATIC FEVER PERSISTENT HEADACHE HEART MURMUR SEIZURE DISORDER ANEMIA HEART ATTACK LOSS OF CONSCIOUSNESS BLEEDING CHEST PAIN PARALYSIS CANCER ANGINA BACK TROUBLE HEARING DIFFICULTY SKIN RASH ARTHIRITIS GOUT THYROID DISEASE DIABETES UNDUE FATIGUE EXCESSIVE WEIGHT GAIN DEPRESSION OR ANXIETY ANXIETY PAIN DOWN LEG NUMBNESS DOWN LEG ABDOMINAL PAIN GALL BLADDER DISEASE ULCER DISEASE BLOOD IN STOOL VOMITING BLOOD PERSISTENT DIARRHEA VISUAL DIFFICULTY EXCESSIVE WEIGHT LOSS HAVE YOU EVER BEEN HOSPITALIZED? YES NO IF YES, WHERE: REASON: HAVE YOU EVER HAD AN MRI? YES NO IF YES, WHICH BODY PART? REASON: IF YOU HAVE HAD ANY SURGICAL OPERATIONS OR SERIOUS INJURIES NOT LISTED ABOVE, PLEASE DESCRIBE: HAVE YOU EVER HAD TO RECEIVE COMPENSATION FOR ANY INJURY OR ILLNESS RELATED TO YOUR JOB? YES NO COMMENTS: DO YOU HAVE ANY HEALTH PROBLEMS THAT YOU THINK MAY BE RELATED TO YOUR PREVIOUS JOB? YES NO COMMENTS: HAVE YOU EVER BEEN EXPOSED TO THE FOLLOWING? (PLEASE CHECK ALL THAT APPLY): CHEMICALS RADIATION ASBESTOS STERILIZATION PROCEDURES WITH ETHYLENE OXIDE LATEX ANIMALS (EXCLUDING PETS) EXCESSIVE DUST NEEDLESTICKS VIBRATION FUMES PERSISTENT LOUD NOISES COMMENTS: 2

HISTORY & PHYSICAL EVALUATION NAME (LAST, FIRST): DATE: DEPARTMENT: HAVE YOU EVER BEEN REJECTED FOR EMPLOYMENT, LIFE INSURANCE OR MILITARY SERVICE DUE TO A MEDICAL PROBLEM? YES NO COMMENTS: DO YOUHAVE ANY PHYSICAL, MEDICAL OR EMOTIONAL PROBLEMS THAT MIGHT WARRANT SPECIAL ARRANGEMENTS AT WORK? YES NO COMMENTS: DO YOU HAVE ANY MEDICAL COMPLAINTS NOW? YES NO COMMENTS: DO YOU SMOKE? YES NO IF YES, HOW MANY CIGARETTES PER DAY? /DAY IF NO, HAVE YOU EVER SMOKED? YES NO DO YOU DRINK ALCOHOL? YES NO IF YES, AMOUNT: /DAY/WEEK/MONTH HAVE YOU EVER HAD PROBLEMS WITH SUBSTANCE ABUSE? YES NO IF YES, PLEASE EXPLAIN IMMUNIZATION HISTORY MONTH AND YEAR(S) OF IMMUNIZATION OR YEAR OF DISEASE POLIO DIPTHERIA TETANUS MEASLES #1 MEASLES #2 MUMPS RUBELLA HEPATITIS B VARICELLA (CHICKEN POX) IF YOU RECEIVED THE HEPATITIS B VACCINE, ARE YOU ANTIBODY POSITIVE? YES NO TUBERCULOSIS SKIN TEST (PPD) DATE: POSITIVE NEGATIVE DON T KNOW IF POSITIVE, WHEN WAS YOUR LAST CHEST X-RAY? HAVE YOU RECEIVED BCG (TB VACCINE)? YES NO 3

HISTORY & PHYSICAL EVALUATION NAME (LAST, FIRST): DATE: DEPARTMENT: STATEMENT OF CONFIDENTIALITY ALL MEDICAL RECORDS WITHIN OCCUPATIONAL HEALTH ARE CONFIDENTIAL AND WILL NOT BE RELEASED WITHOUT WRITTEN SUTHORIZATION FROM THE EMPLOYEE OR PURSUANT TO GOVERNMENT AUTHORIZATION. VERIFICATION OF INFORMATION THE ABOVE STATEMENTS ARE TRUE TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT ANY FALSE STATEMENT MADE PURPOSELY MAY BE GROUNDS FOR WITHDRAWAL OF OFFER OR TERMINATION OF EMPLOYMENT. I UNDERSTAND THAT THE PRE-EMPLOYMENT PHYSICAL EXAMINATION IS INTENDED ONLY TO DETERMINE WHETHER OR NOT I CAN SAFELY PERFORM THE JOB TASKS AND TO ESTABLISH A BASELINE OF MY HEALTH STATUS. I UNDERSTAND THAT IT DOES NOT REPLACE THE MEDICAL CARE PROVIDED BY MY PERSONAL PHYSICIAN NOR IS IT A COMPREHENSIVE MEDICAL EXAMINATION. SIGNATURE DATE 4

HISTORY & PHYSICAL EVALUATION NAME (LAST, FIRST): DATE: DEPARTMENT: VISUAL TESTING FOR COLOR DEFICIENCY Plate # Normal Red-Green Deficiencies Total Color Blindness and Weakness 1 12 12 12 2 8 3 X 3 5 2 X 4 29 70 X 5 74 21 X 6 7 X X 7 45 X X 8 2 X X 9 X 2 X 10 16 X X 11 Traceable X X Protan Deutan Strong Mild Strong Mild 12 35 5 (3)5 3 3(5) 13 96 6 (9)6 9 9(6) 14 Can trace 2 lines Purple Purple (red) Red Red (purple) The X mark shows that the plate cannot be read. The numerals and winding lines in parenthesis show that they can be read or traced but they are comparatively unclear. X RESULTS: NORMAL: RED-GREEN DEFICIENT: COLORBLIND/WEAK: TESTER S SIGNATURE: 5

HISTORY & PHYSICAL EVALUATION NAME (LAST, FIRST): DATE: DEPARTMENT: TEMP PULSE BP / HT WT GENERAL HEALTH NORMAL ABNORMAL NOT EXAMINED REMARKS SKIN EAR EOMS PUPILS FUNDI NOSE/MOUTH CAROTIDS THYROID LYMPH NODES LUNGS HEART ABDOMEN EXTREMITITES CRANIAL NERVES MOTOR SENSORY REFLEXES VISION OD OS CORRECTED OD OS REFERRALS, RISK FACTORS, COMMENTS, ETC.: MEDICAL PROVIDER S SIGNATURE/NAME DATE/TIME 6