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Medical History Questionnaire

Birth Date  
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Sex  


Please Mark the Boxes Where the Following Conditions Apply to You
Do you currently smoke tobacco, or have you smoked tobacco in the last month?  


If you do Smoke, How Many Packs Per Day?





Do You Consume Alcoholic Beverages?  


If Yes, How Many Drinks Per Week?






Do You Currently Use Drugs Such as Marijuana, Cocaine, or Other Similar or Illegal Drugs?  


Have You Had Any Surgeries And/Or Hospitalizations?  


Do You Have Allergies?  


The purpose of this information is to establish a medical history. This is retained by UVA-WorkMed and becomes part of your medical record.
Have you EVER HAD any of the following conditions(you can check more than 1 if you need)?
Have you EVER HAD any of the following pulmonary or lung problems(choose any or all that apply)?
Have you EVER HAD any of the following cardiovascular or heart symptoms?
Do you CURRENTLY take medication for any of the following problems?
Would you like to talk to the health care professional who will reveiw this questionnaire about your answers to this questionnaire?  


Have you EVER LOST vision in either eye?  


Do you CURRENTLY have any of the following vision problems?
Have you EVER HAD an injury to your ears, including a broken ear drum?  


Do you CURRENTLY have any of the following hearing problems?
Have you EVER HAD a back injury?  


Do you CURRENTLY have any of the following musculoskeletal problems?
Please mark any or all of the following if you are experiencing:
Todays Date  
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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:

  • Fit-for-duty status

to:

  • Albemarle County Police Department
  • Albemarle County Department of Human Resources

for the purposes of:

  • Fulfilling employment requirements and occupational medical program requirements

 

 

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 Police Department

for the purpose of:

  • Data collection, reporting, and research

 

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.

Today's Date  
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