Employee Health Form

EXHIBIT H—Employee Health Form
_________________________________________________
Employee Name (Print Please)
EMPLOYEE HEALTH FORM
□ STATEMENT OF SATISFACTORY HEALTH ([ X ] IF THIS SECTION IS TO BE COMPLETED)
___________________________________, is found to be in good health without evidence of communicable disease and free of work
restrictions on this date. Date of last physical exam: ______________________
Date of 1st Mantoux: _______ Results: ________MM Date: _______ Signature/Title: __________________________
Date of 2nd Mantoux: _______ Results: ________MM Date:_______ Signature/Title: __________________________
Date of Chest X-ray: _______ Results: ___________________________________________________________________________
□ Repeat Chest X-ray required on ____/____/____ □ Other: ______________________________________

□ Repeat Chest X-ray with development of symptoms
Signed: _____________________________________________ Date: ___________________________________________
Physician or Licensed Nurse Practitioner or PA
□ EMPLOYEE HEALTH HISTORY ([ X ] IF THIS SECTION IS TO BE COMPLETED) DATE: ______________

COMPLETED BY: □ SUPERVISING RN □ PHYSICIAN/LICENSED NURSE PRACTITIONER/PA
Yes No Yes No Yes No Yes No In last 12 months:
□ □ Diabetes □ □ Shortness of Breath □ □ Stroke □ □ Hospitalized

□ □ Heart Disease □ □ Asthma/Bronchitis □ □ Kidney Disease □ □ Lung disease
□ □ Tuberculosis □ □ Epilepsy/seizures □ □ Unexplained Fever □ □ Back/Spinal

problems
□ □ Hepatitis B □ □ Mental Disorder Other _________________ ____________
Do you have any of these conditions or any other conditions which might cause risk to the patient or could potentially interfere with the
performance of one’s duties, including the habituation of alcohol or current addiction to depressants, stimulates, narcotics, or other substances.
Do any of these conditions impair your ability to perform the essential functions of the job, if “yes”, please explain/give dates:______________
___________________________________________________________________________________________________________________
Had Disease Dates (Month/Year) Had Disease Dates (Month/Year)

DISEASE Yes No Year Titer Results Vaccination Disease Yes No Year Titer Results Vaccination
Chicken Pox Mumps
Measles Ger. Measles
(Rubeola) (Rubella)
Employee Signature:__________________________________ Practitioner Signature/Title: ___________________________
□ EMPLOYEE HEALTH EXAMINATION RECORD ([ X ] IF THIS SECTION IS TO BE COMPLETED)

Blood Pressure_________T_________P_________R_________ Height___________ Weight____________
Ears: _________________________ Abdomen: _____________________ Hernia: ____________________
Eyes:_________________________ GU History: ____________________ GI History: __________________
Teeth: ________________________ Skin: __________________________ Extremities: __________________
Nose & Throat: _________________ Scars: _________________________ Other: ______________________
Lungs: ________________________ Heart: _________________________ ____________________________
Major Illnesses/Operations/Injuries: _____________________________________________________________________________________
Work Restrictions □ Yes □ No If “yes,” explain: ______________________________________________________________
Physical accommodations required to perform essential functions of the job. If applicable explain: _______________________________
______________________________________________________________________________________________________________
May safely wear HEPA mask □ Yes □ No If “no,” explain: __________________________________________________
_______________________________ is found to be in good health without evidence of communicable disease, is free from health impairment
which may cause risk to the patient or which might interfere with his or her duty including the habituation of alcohol, addiction to depressants,
stimulants, narcotics, or other drugs or substances which may alter your behavior.
Signed: ______________________________________________ Date: ____________________________________

Physician or Licensed Nurse Practitioner or PA

Employee Health Form

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EXHIBIT H—Employee Health Form

□ STATEMENT OF SATISFACTORY HEALTH ([ X ] IF THIS SECTION IS TO BE COMPLETED)

□ Repeat Chest X-ray required on // □ Other: __________________________________

□ EMPLOYEE HEALTH HISTORY ([ X ] IF THIS SECTION IS TO BE COMPLETED) DATE: ______________

□ □ Diabetes □ □ Shortness of Breath □ □ Stroke □ □ Hospitalized

□ □ Tuberculosis □ □ Epilepsy/seizures □ □ Unexplained Fever □ □ Back/Spinal

Had Disease Dates (Month/Year) Had Disease Dates (Month/Year)

Employee Signature:________ Practitioner Signature/Title: _

□ EMPLOYEE HEALTH EXAMINATION RECORD ([ X ] IF THIS SECTION IS TO BE COMPLETED)

Signed: __________ Date:

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