NEW EMPLOYEE HEALTH HISTORY (Please Print)
(Label)
Personal Information
Name:
Race:
Date of Birth:
Sex:
Social Security#:
Marital Status:
Address:
City:
State:
Daytime Telephone:
Department Name & Extension:
Zip Code:
E-mail address:
Please check all that apply:
Skin rashes or skin irritation
Hives
Reaction to soap/detergents
Glasses for reading
Glasses for distance vision
Wear contact lenses
Color blind
Other visual problems
Difficulty hearing
Use hearing aide(s)
Chest pain
High blood pressure
High cholesterol
Shortness of breath
Swelling of the ankles
Heart murmur
Heart palpitations
Heart surgeries
Seasonal allergies
Chronic cough
Asthma, bronchitis or COPD
Cough with blood
History of positive TB Skin Test
History of receiving BCG Vaccine
Back or neck pain or injury
Vertebral disc problems
History of falling
Sacroiliac pain
Missed work due to back pain
Shoulder or arm pain or injury
Leg or knee pain or injury
Swollen joints
Arthritis or gout
Bursitis or tendonitis
Trouble walking / standing for > 1 hour
Trouble sitting for long periods
Back or neck surgery
Shoulder, elbow, wrist, hand surgery
Knee, ankle or foot surgery
Facial or dental surgery
Arm, wrist or hand weakness
Leg, knee, ankle or foot weakness
Arm or leg numbness
Dizziness, fainting spells
Frequent / severe headaches
Seizures or convulsions
Multiple sclerosis
Neuromuscular disorder
Cirrhosis, Jaundice, Hepatitis
Gastritis or GERD
Hernia repair
Abdominal surgery
Excessive weight loss/gain
Anemia or polycythemia
Night sweats
Diabetes
Hypo or Hyper thyroid or goiter
Kidney problems
Chicken Pox
Shingles
Red Measles (Rubeola)
Mumps
Previous Jobs Involving:
Highly repetitive motions
Power / vibration tools
Laser
Exposure to dust / fumes / chemicals
Any difficulty working due to:
Stress, anxiety, or depression
Smoke cigarettes
Use other tobacco products
List allergies to medications:
Are you allergic to rubber, latex or powder in gloves?
Do your lips swell or itch after you blow up a balloon?
Have you had swelling, itching or trouble breathing/swallowing during dental procedures?
Have you had eczema or rashes on your hands?
Have you had rashes, hives or other reactions to wearing gloves or to powder in gloves?
Are you allergic to fruits, vegetables, seafood, peanuts, iodine, etc? (Please explain)
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
SEASONAL INFLUENZA VACCINATION POLICY FOR ALL GRMC, GRU, LEASED, VOLUNTEERS, CONTRACTORS, CREDENTIALED PROVIDERS: I have been
informed and understand that the vaccination is a condition of my employment and refusing to comply with the policy will result in termination of
employment: ________________________________________________________________________(Signature)
What medications do you currently take?
List surgical procedures (date):
Have you had any accident, injuries or medical conditions that have prevented you from doing your work related duties in the past? YES
(If yes, please explain)
Are you medically capable of performing all critical functions of your job descriptions as detailed by Human Resources? YES NO
(If no, please explain)
Do you anticipate the need for any accommodations to perform the duties of your job description? YES NO
(If yes, please explain)
_________________________________________________________
EMPLOYEE SIGNATURE:
03.04.13 Rev
NO
__________________________________________________________
DATE: