"Pre-employment History and Physical Form - Temple University"

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Pre-Employment History and Physical Form
Personal Data
Name (Last, First, MI):
SSN:
:
/
/
Date of Birth
Age:
Ethnicity:
Phone Numbers:
Home (
)
-
Mobile (
)
-
Work (
)
-
Address:
(street)
(city)
(state)
(zip)
Job Title & Department:
Union:
If yes, specify:
Yes
No
Current Medical Provider
Name of doctor:
Phone Number: (
)
-
Address:
(street)
(city)
(state)
(zip)
Prior Employment
Start with most recent job
Job Title
Employer/City/State
Dates of employment (mo/yr)
1
/
/
to
2
/
/
to
3
/
/
to
4
/
/
to
Review of Symptoms
Do you have any of the following?:
Do you have any of the following?:
Yes No
Yes No
Weight loss / Weight gain (circle)
Palpitations or skipped beats
Fevers
Chest pain or tightness
Headaches
Indigestion/heartburn
Difficulty with vision / Wear lenses or glasses
Abdominal pain
Dizziness / Vertigo
Diarrhea/constipation
Difficulty hearing
Irregular periods
Seasonal allergies
Frequent urinary tract infections
Sinus problems
Kidney stones
Tiredness or falling asleep during the day
Back pain
Unable to tolerate heat or cold
Joint pain or swelling
Shortness of breath with or without exertion
A history of broken bones
Wheezing
Swelling of the legs
Cough
Skin problems (rash, eczema, psoriasis)
Vaccination History/Communicable Diseases
Have you had:
Yes
No
Unsure
The standard series of childhood vaccinations (to the best of your knowledge)?
The disease “chicken pox” or the chicken pox vaccine (varicella)?
A tetanus/diphtheria booster shot within the last 10 years?
Hepatitis B vaccination (this is a series of three injections spaced several months apart)?
The disease “Tuberculosis”?
A positive tuberculosis test (also called a PPD or Tine test)?
Vaccination against tuberculosis with BCG (this is uncommon in the United States)?
Pre-Employment History and Physical Form
Personal Data
Name (Last, First, MI):
SSN:
:
/
/
Date of Birth
Age:
Ethnicity:
Phone Numbers:
Home (
)
-
Mobile (
)
-
Work (
)
-
Address:
(street)
(city)
(state)
(zip)
Job Title & Department:
Union:
If yes, specify:
Yes
No
Current Medical Provider
Name of doctor:
Phone Number: (
)
-
Address:
(street)
(city)
(state)
(zip)
Prior Employment
Start with most recent job
Job Title
Employer/City/State
Dates of employment (mo/yr)
1
/
/
to
2
/
/
to
3
/
/
to
4
/
/
to
Review of Symptoms
Do you have any of the following?:
Do you have any of the following?:
Yes No
Yes No
Weight loss / Weight gain (circle)
Palpitations or skipped beats
Fevers
Chest pain or tightness
Headaches
Indigestion/heartburn
Difficulty with vision / Wear lenses or glasses
Abdominal pain
Dizziness / Vertigo
Diarrhea/constipation
Difficulty hearing
Irregular periods
Seasonal allergies
Frequent urinary tract infections
Sinus problems
Kidney stones
Tiredness or falling asleep during the day
Back pain
Unable to tolerate heat or cold
Joint pain or swelling
Shortness of breath with or without exertion
A history of broken bones
Wheezing
Swelling of the legs
Cough
Skin problems (rash, eczema, psoriasis)
Vaccination History/Communicable Diseases
Have you had:
Yes
No
Unsure
The standard series of childhood vaccinations (to the best of your knowledge)?
The disease “chicken pox” or the chicken pox vaccine (varicella)?
A tetanus/diphtheria booster shot within the last 10 years?
Hepatitis B vaccination (this is a series of three injections spaced several months apart)?
The disease “Tuberculosis”?
A positive tuberculosis test (also called a PPD or Tine test)?
Vaccination against tuberculosis with BCG (this is uncommon in the United States)?
Have you ever had:
a car accident
loss of consciousness
heart attack
loss of vision
abnormal heart rhythm
seizure
panic attacks
head injury
stroke
paralysis
back injury
psychiatric disorder
Current Medical Conditions
Those that you are currently experiencing and/or receiving treatment for (such as diabetes, high blood pressure, migraine)
Please List
Please List
Date of onset (mo/yr)
Date of onset (mo/yr)
1
5
/
/
2
6
/
/
3
7
/
/
4
8
/
/
Past Medical Conditions
Those that you have had in the past but have recovered from (such as childhood asthma, gestational diabetes)
Please List
Please List
Date of onset (mo/yr)
Date of onset (mo/yr)
1
3
/
/
2
4
/
/
Surgeries/Hospitalizations
List type of surgery (such as gall bladder) or condition for which you were hospitalized (such as heart attack, pneumonia)
Please List
Date (mo/yr)
Please List
Date (mo/yr)
1
4
/
/
2
5
/
/
3
6
/
/
When was your last visit to the emergency room? _________ For what symptom/condition? ___________
Family History
Please list any conditions that run in your biological family (even if relative is deceased)
Please List
Please List
Circle affected relative
Circle affected relative
Father / Mother / Sister / Brother /
Father / Mother / Sister / Brother /
4
1
Child / Grandmother / Grandfather
Child / Grandmother / Grandfather
Father / Mother / Sister / Brother /
Father / Mother / Sister / Brother /
5
2
Child / Grandmother / Grandfather
Child / Grandmother / Grandfather
Father / Mother / Sister / Brother /
Father / Mother / Sister / Brother /
6
3
Child / Grandmother / Grandfather
Child / Grandmother / Grandfather
Medications
Please include non-prescription medications, vitamins, and herbal supplements in addition to prescription medications
1
4
7
2
5
8
3
6
9
Do you have any allergies to medications or other substances?
Yes
No
(if yes, please specify on next line)
__________________________________________________________________________________________
Social History
Do you smoke cigarettes?
yes /
no /
used to smoke, but quit
If yes, how many cigarettes per day? ______ Per week? ______
How many alcoholic drinks do you consume per day? _______ Per week? _______
Do you use illicit/illegal drugs?
yes /
no
How many minutes of exercise do you get per day? ________
How many days a week do you exercise? _________
How many hours of television do you watch per day? ________
How many times do you eat fast food per week? ________
Occupational Assessment
Please answer the following questions regarding the job for which you have been hired:
Yes
No
Unsure
Will you be required to wear respiratory protection (e.g., N95 mask or cartridge respirator)?
Do you anticipate working with hazardous chemicals or materials, infectious agents, or laboratory animals?
Is there a chance that you will be exposed to human blood or body fluids as a result of routine job duties?
If your job involves work at a computer, have you had or are you experiencing any discomfort, pain, or
numbness when working at your desk?
Will you be required to drive a vehicle for any reason?
Will you be required to move heavy objects regularly (i.e., greater than 50 pounds occasionally or 25 pounds
frequently)?
Have you ever had an occupational injury/illness before (e.g., back strain, needle-stick, chemical exposure)?
Do you have any condition (physical, medical, or psychological) that would require special
accommodations in order for you to perform your job?
Yes
No
(if yes, please specify on next lines)
__________________________________________________________________________________________
__________________________________________________________________________________________
Signature of employee: ____________________________________________
Date: __________________
Practitioner Notes: __________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Physical Examination
Height
Weight
BMI
Blood Pressure
Pulse
Respirations Temperature
Vision:
Uncorrected / Corrected (circle): OD - ____/____ OS - ____/____ OU - ____/____
HEENT:
__________________________________________________________________________
Neck:
__________________________________________________________________________
Chest/Lungs:
__________________________________________________________________________
Heart:
__________________________________________________________________________
Abdomen:
__________________________________________________________________________
Musculoskeletal: __________________________________________________________________________
Neurological:
__________________________________________________________________________
Skin:
__________________________________________________________________________
Other:
__________________________________________________________________________
__________________________________________________________________________
Assessment: ______________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Practitioner signature: ___________________________________________ Date: _______________________
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