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Home > Occupational Health > Employee Know Before You Go: Before Your Visit > City of Charlottesville > FIRE/EMS: Initial Medical Clearance > Health History Questionnaire > Health History Questionnaire

Health History Questionnaire

Birth Date  
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Sex  


Date of Employment
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Are you a Volunteer?  


Are you under the age of 18?  


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


Are you allergic to any medications?  


Do you have any chronic dermatitis?  


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


Have you ever had the tetanus vaccine?  


Do you wear corrective lenses?  


Do you have any chronic eye conditions?  


Do you have any trouble identifying colors?  


Do you have any loss of hearing?  


Do you have hay fever?  


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


Do you smoke cigarrettes?  


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


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


Do you have trouble with dizziness and lightheadedness?  


Do you ever get pains or tightness in your chest?  


Do you often have difficulty in breathing?  


Do you often have trouble with swollen feet or ankles?  


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


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


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


Have you frequently had episodes of dizziness or fainting?  


Do you have frequent headaches?  


Has your vision ever been effected by headaches?  


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


Are you often bothered by severe itching?  


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


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


Have you ever had any sensitivity to chemicals?  


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


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


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?
If you've used a respirator, have you EVER HAD 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?
Have you ever had Eczema?  


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


Have people annoyed you by criticizing your drinking?  


Have you ever felt bad or guilty about your drinking?  


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


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


Do you have any chronic illnesses?  


Have you ever had chickenpox?  


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


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


Have you received the Polio vaccination?  


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


Have you ever coughed up blood?  


Do you sometimes have severe soaking sweats at night?  


Have you ever had tuberculosis?  


Have you ever lived with anyone who had tuberculosis?  


Have you ever received the Hepatitis B vaccine?  


Have you ever received the Hepatitis A vaccine?  


Do you frequently have diarrhea?  


Have you ever had yellow jaundice/hepatitis?  


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


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


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


Have you ever been addicted to or constantly using drugs?  


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


Please mark any/all of the following items that you have had an allergic reaction to within one hour of exposure? (Reactions include itching, redness, swelling, hives, runny nose, congestion, wheezing or chest tightness)
Do you have personal history of any of the following? ( you can mark more than one box)
Do you carry an epinephrine (EpiPen/AnaKit)?  


Do you have any food allergies?  


If you do have food allergies, are you allergic to any of the following? (Common symptoms are mouth tingling, lip swelling, itchy throat, rhinorrhea, wheezing, urticaria or nausea)
Have you ever had any adverse reactions or complications to any previous surgeries?  


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


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


Do you have a hernia (rupture)?  


Have you ever had a surgical repair for a hernia?  


Are your joints often painfully swollen?  


Do your muscles and joints feel stiff on arising?  


Do you usually have pain in the arms and legs?  


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


Do your feet constantly hurt/ache?  


Are you ever stiff and sore after heavy work?  


Have you ever been told not to lift heavy objects?  


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


Have you ever had back or neck surgery?  


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


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


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


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


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


Has any part of your body ever been paralyzed?  


Have you ever had knee surgery?  


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


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


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


Have you ever been told you stop breathing during sleep?  




How often do you snore?  




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


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


If applicable: Date of positive PPD?
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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:

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

to:

  • Charlottesville City Fire Department

for the purpose of:

  • Data collection, reporting, and research

 

I further authorize the release and disclosure of:

  • Fit-for-duty status

to:

  • Charlottesville City Department of Fire and Rescue
  • Charlottesville City 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.

Today's Date  
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