Health History Questionnaire

Email Address

Last Name

First Name

Middle/Maiden Name

Birth Date

Year / Month / Day

Sex

Male
Female

In What Country Were you Born?

Date of Employment

Year / Month / Day

Are you a Volunteer?

Yes
No

If you answered Yes to being a Volunteer please inidicate below what station you are Volunteering for?

Are you under the age of 18?

Yes
No

Job Classification

Department

Work Phone #

Home Address

Home Phone

Check if there is any family history of the following diseases (you may check more than one box)

Tuberculosis

Kidney Disease

High Blood Pressure

Arthritis

Cancer

Epilepsy

Heart Disease

Diabetes

Do you take any medications regularly?

Yes
No

If you answered Yes to above question please list medications below

Are you allergic to any medications?

Yes
No

If you answered Yes to above question please list medications you are allergic to

Do you have any chronic dermatitis?

Yes
No

If you answered Yes to chronic dermatitis please explain below

Do you have any moles that have changed color or gotten larger?

Yes
No

Have you ever had the tetanus vaccine?

Yes
No

Date of Tetanus Vaccine

Date of last tetanus booster

Do you wear corrective lenses?

Yes
No

Do you have any chronic eye conditions?

Yes
No

Do you have any trouble identifying colors?

Yes
No

Do you have any loss of hearing?

Yes
No

Do you have hay fever?

Yes
No

Have you ever had a chronic breathing condition (emphysema, bronchitis)?

Yes
No

Do you smoke cigarrettes?

Yes
No

If you smoke cigarrettes, how many per day?

Has a doctor ever said your blood pressure was too high?

Yes
No

Have you ever been bothered by a thumping or racing heart?

Yes
No

Do you have trouble with dizziness and lightheadedness?

Yes
No

Do you ever get pains or tightness in your chest?

Yes
No

Do you often have difficulty in breathing?

Yes
No

Do you often have trouble with swollen feet or ankles?

Yes
No

Have you ever been told that you have a heart murmur, or any other heart condition?

Yes
No

Do you have trouble stopping even a small cut from bleeding?

Yes
No

Have you ever had a seizure or convulsion (epilepsy)?

Yes
No

Have you frequently had episodes of dizziness or fainting?

Yes
No

Do you have frequent headaches?

Yes
No

Has your vision ever been effected by headaches?

Yes
No

Do cuts in your skin take a long time to heal?

Yes
No

Are you often bothered by severe itching?

Yes
No

Are you aware of any unexplained "knots", "bumps", lymph nodes or masses?

Yes
No

Following a bowel movement, have you ever noticed blood in your stool or in the toilet?

Yes
No

Have you ever had any sensitivity to chemicals?

Yes
No

Do you currently smoke tobacco, or have you smoked tobacco in the last month?

Yes
No

Check the type of respirator you will use (you can check more than one category)

N, R, or P disposable respirator (filter-mask, non-cartridge type only)

Other Type (example: half or full face piece type, power-air purifying, supplied-air, self-contained breathing apparatus)

Unknown

Have you worn a respirator?

Yes
No

If yes, what type(s) of respirator?

Have you EVER HAD any of the following conditions(you can check more than 1 if you need)?

Seizures

Diabetes

Allergic reactions that interfere with your breathing

Claustrophobia

Trouble smelling odors

Have you EVER HAD any of the following cardiovascular or heart symptoms?

Frequent pain or tightness in your chest

Pain or tightness in your chest during physical activity

Pain or tightness in your chest that interferes with your job

In the past two years, have you noticed your heart skipping or missing a beat

Heartburn or indigestion that is not related to eating

Any other symptoms that you think might be related to heart or circulation problems

Do you CURRENTLY take medication for any of the following problems?

Breathing or lung problems

Heart trouble

Blood pressure

Seizures

If you've used a respirator, have you EVER HAD any of the following problems?

Eye Irritation

Skin allergies or rashes

Anxiety

General Weakness

Any other problem that interferes with your use of a respirator

Would you like to talk to the health care professional who will reveiw this questionnaire about your answers to this questionnaire?

Yes
No

Have you EVER LOST vision in either eye?

Yes
No

Do you CURRENTLY have any of the following vision problems?

Wear contact lenses

Wear glasses

Color blind

Any other eye or vision problems

Have you EVER HAD an injury to your ears, including a broken ear drum?

Yes
No

Do you CURRENTLY have any of the following hearing problems?

Difficulty hearing

Wear a hearing aid

Any other hearing or ear problem

Have you EVER HAD a back injury?

Yes
No

Have you ever had Eczema?

Yes
No

Have you ever felt you should you cut down on your drinking?

Yes
No

Have people annoyed you by criticizing your drinking?

Yes
No

Have you ever felt bad or guilty about your drinking?

Yes
No

Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover?

Yes
No

Have you ever been hospitalized for any illness, injury or surgery?

Yes
No

Do you have any chronic illnesses?

Yes
No

Have you ever had chickenpox?

Yes
No

Have you ever had a rubella titer (German Measles) drawn?

Yes
No

Have you ever had a measles, mumps, and or rubella vaccine?

Yes
No

Have you received the Polio vaccination?

Yes
No

Have you ever had a reaction (redness or swelling) to a tuberculin skin test?

Yes
No

Have you ever coughed up blood?

Yes
No

Do you sometimes have severe soaking sweats at night?

Yes
No

Have you ever had tuberculosis?

Yes
No

Have you ever lived with anyone who had tuberculosis?

Yes
No

Have you ever received the Hepatitis B vaccine?

Yes
No

Have you ever received the Hepatitis A vaccine?

Yes
No

Do you frequently have diarrhea?

Yes
No

Have you ever had yellow jaundice/hepatitis?

Yes
No

Have you ever been told that you have a chronic liver disease?

Yes
No

Have you ever been hospitalized for mental illness or nervous breakdown?

Yes
No

Have you ever received psychiatric treatment or been advised by a doctor to have it?

Yes
No

Have you ever been addicted to or constantly using drugs?

Yes
No

Have you been told by a physician that you have an allergy to any latex product?

Yes
No

Do you have personal history of any of the following? ( you can mark more than one box)

Asthma

Conjunctivitis

Eczema

Urticaria (itching)

Contact Dermatitis (rash)

Rhinitis (runny nose)

Do you carry an epinephrine (EpiPen/AnaKit)?

Yes
No

If you answered Yes to carrying epinephrine...what do you carry it for?

Do you have any food allergies?

Yes
No

Have you ever had any adverse reactions or complications to any previous surgeries?

Yes
No

How many previous surgeries have you had?

Have you had any physical problems while having dental work completed?

Yes
No

Do you have any congenital abnormalities? (e.g. spina bifida?)

Yes
No

If you answered Yes to having a congenital abnormality, what type?

Do you have a hernia (rupture)?

Yes
No

Have you ever had a surgical repair for a hernia?

Yes
No

Are your joints often painfully swollen?

Yes
No

Do your muscles and joints feel stiff on arising?

Yes
No

Do you usually have pain in the arms and legs?

Yes
No

Do you have a diagnosis of arthritis, osteoarthritis or rheumatoid arthritis?

Yes
No

Do your feet constantly hurt/ache?

Yes
No

Are you ever stiff and sore after heavy work?

Yes
No

Have you ever been told not to lift heavy objects?

Yes
No

Have you ever had a back/neck injury/strain?

Yes
No

Have you ever had back or neck surgery?

Yes
No

Have you ever had a back or neck injury that required you to miss work, restrict activity, or require bed rest?

Yes
No

(Males) Have you had a prostate exams within the last year?

Yes
No

(Males) Do you regularly perform self-testicular examination?

Yes
No

(Females) Do you regularly perform a self-breast examination?

Yes
No

(Females) Have you had a gynecological exam within the last year?

Yes
No

Has any part of your body ever been paralyzed?

Yes
No

If you answered Yes to being paralyzed....Tell us when and what part below

Have you ever had knee surgery?

Yes
No

Do you have a physical condition that limits your activity or prevents you from performing certain body movements such as bending, lifting or squatting?

Yes
No

Do you regularly exercise? (running, jogging, swimming, walking, bicycling, aerobics, etc)

Yes
No

Do you play any sport regularly (softball, tennis, basketball)?

Yes
No

Have you ever been told you stop breathing during sleep?

Never
Sometimes (<3 nights a week)
Often (3-7 nights a week)
Uncertain

How often do you snore?

Never
Moderate (<3 nights a week)
Most Nights (3-7 nights a week)
Uncertain

History of positive TB skin test means that sometime during your life you have come in contact with tuberculosis bacteria. It does not mean you have active tuberculosis right now.

Are you experiencing any of the following signs and symptoms of Tuberculosis? (you can mark more than 1)

Unexplained severe night sweats

Unexplained weight loss

Bad cough lasting longer than 2 weeks

Persistent low grade fever

Coughing up blood or sputum

Extreme weakness or fatigue

Loss of appetite

Have you been exposed to anyone with tuberculosis since your last annual assessment?

Yes
No

Have you taken any medication for tuberculosis after having a positive skin test?

Yes
No

If applicable: Date of positive PPD?

Year / Month / Day

Signature Of Person Filling Out Form: Type Name Below

Todays Date

Year / Month / Day

HIPPA Release and Authorization for Use and Disclosure of Protected Information

The Health Insurance Portablity and Accountability Act of 1996 (HIPAA) established regulations which require healthcare providers to ensure they are protecting the privacy and security of patients' medical information.

By signing this form, I authorize the University of Virginia Health System & UVA WorkMed to disclose to:

Me, the individual patient or legal authority

the following protected information:

Annual physical exam results

I further authorize the release and disclosure of:

Non-identifiable raw data and medical component data points as listed in my Pre-Exam Instructions

to:

Albemarle County Department of Fire Rescue

for the purpose of:

Data collection, reporting, and research

I further authorize the release and disclosure of:

Fit-for-duty status

to:

Albemarle County Department of Fire Rescue
Albemarle County Department of Human Resources

for the purposes of:

Fulfilling employment requirements and occupational medical program requirements

Please Read and Initial Below

I understand that, by federal law, the University of Virginia Health System and UVA WorkMed may not use or disclose

my health information, without my authorization. My signature on this Authorization indicates that I am giving

permission for the uses and disclosures of the protected health information described above. I hereby release the

University of Virginia Health System and UVA WorkMed and its employees from any and all liability that may arise

from the release of information as I have directed.

I understand that I have the right to revoke this Authorization at any time. If I want to revoke this authorization, I must

do so in writing, and address it to the person or institution named above that I am authorizing to disclose my

information. I understand that if I revoke this authorization, it will not apply to any information already released as a

result of this authorization.

I understand that I may refuse to sign this Authorization. I also understand that the institutions or individuals named

above cannot deny or refuse to provide treatment, payment, enrollment in a health plan, or eligibility for benefits if I

refuse to sign this Authorization.

I understand that, once information is disclosed pursuant to this Authorization, it is possible that it will no longer be

protected by the federal medical privacy law and could be disclosed by the person or agency that receives it.

This authorization automatically expires 365 days from the date of my annual physical exam.

I have read and understand the information in this Authorization

Name of Patient or Legal Authority who checked above box

Today's Date

Year / Month / Day