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

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.
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?
PPD Assessment: History of a positive TB skin test means that sometime during your life you have come in contact with the tuberculosis bacteria. It does not mean you have active Tuberculosis right now.
Please mark any or all of the following if you are experiencing:
Have you been exposed to anyone with tuberculosis since your last annual assessment?  


Have you taken any medication for tuberculosis since your last annual assessment?  


If applicable: Date of positive PPD?
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Hours of sleep each night  




Hours exercised per week  




Alcoholic drinks per week (1 drink = 12oz beer, 5oz wine, 1.5oz liquor)  




Meals eaten out per week  




Do you have any downtime or participate in quiet mindfulness activites? (Pilates, yoga, meditation, quiet walks, personal hobbies)  


Do you have any downtime or participate in quiet mindfulness activites? (Pilates, yoga, meditation, quiet walks, personal hobbies)  


The following fields need to be added together to tally your total stress level at the end
Please answer the following questions based on your experience within the LAST MONTH

If your total number above equaled:

20-40:  Stress is fairly well managed in your life.  It may be important to support your body to continue its healthy response.

40-80:  Your body's response to stress may be getting in the way of normal activities quite frequently, leaving you feeling depleted.  Consult your health care professional for an individualized program to achieve your health goals.

80-100: You may have experienced prolonged stress, and your body's stress response can no longer adapt or successfully cope.  Consult your health care professional for targeted support and strategies for improvement.

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:

  • Charlottesville City Department of Fire Rescue
  • Charlottesville City 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:

  • Charlottesville City Department of Fire Rescue

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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