University of Washington
CAMPUS HEALTH SERVICES
MEDICAL SURVEILLANCE HEALTH/WORK SCREENING QUESTIONNAIRE
CONFIDENTIAL INFORMATION
DATE: __________________________
NAME____________________________________ EID#_____________________________
PREVIOUS NAME(S)____________________________ WORK PHONE________________
DEPT/JOB TITLE__________________________ PI/SUPERVISOR____________________
BIRTHDATE___________________M____ F ____
BUDGET #______________________
EMERGENCY NUMBER_________________________ BOX NUMBER_________________
MEDICAL HISTORY
□ Good
□ Fair
Have you had a prior history of the following conditions □ Yes
□ No ?
Do you consider your health to be:
□ Excellent
□ Poor
If Yes; Please indicate the condition and enter date of onset:
Condition
Arthritis
Asthma
Diabetes
Cancer
Back/Joint Pain
Stomach/intestinal problems
Hearing Loss
Heart Disease
Heart Murmur/Valve Disease
High Blood Pressure
Immunosuppression/deficiency
Kidney Disease
Liver Disease
Loss of Consciousness
Lung/Breathing problems
Rheumatic Fever
Seizures
Tuberculosis
Yes
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FEMALES ONLY:
Are you pregnant, breastfeeding or planning on becoming pregnant in the next year?
□ YES
□ NO
U:EHC/clinical./forms/Health Clearance Questionnaire_2008
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University of Washington
CAMPUS HEALTH SERVICES
MEDICAL SURVEILLANCE HEALTH/WORK SCREENING QUESTIONNAIRE
IMMUNIZATION HISTORY
To the best of your knowledge have you had your primary childhood vaccines?
□ Yes □ No
Please check vaccines/titers received in the past 20 years, with date/results:
CheckVACCINE/TITER
Date
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Anthrax
BCG
Influenza (current year)
Hepatitis B (3 shot series)
Hepatitis B titer ______
Meningococcal meningitis
Measles/Mumps/Rubella
Measles/Mumps/ Rubella Titer
Pneumoncoccal
Polio Rabies (3 shot series)
Rabies Titer
Tetanus/Diphtheria
Tdap (Td with Pertussis)
Tularemia
Varicella (Chickenpox)
Vaccinia/Smallpox
Varicella Titer
Zostervax (Shingles)
Results
TUBERCULOSIS TESTING
□ Yes
Have you ever had a TB (PPD) Skin test?
□ Positive
Date of last test: ________________ Results:
□ No
□ Negative
If positive, date of last Chest X-ray ________________
Did you take preventive INH Therapy
□ Yes
□ No
If yes, Date: _________________
ALLERGIES:
Do you have any allergies?
□ Yes
□ No
If yes, please check it describe symptoms:
Check Allergy
Describe
□ Medication
___________________________________________________________
□ Environmental
___________________________________________________________
□ Latex
___________________________________________________________
□ Animal
___________________________________________________________
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___________________________________________________________
Other
U:EHC/clinical./forms/Health Clearance Questionnaire_2008
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University of Washington
CAMPUS HEALTH SERVICES
MEDICAL SURVEILLANCE HEALTH/WORK SCREENING QUESTIONNAIRE
HABITS:
Do you smoke tobacco?
□ Yes
□ No
□ Smoked in the past :
Quit: ______years ago
PAST MEDICAL EVENTS:
Please list past surgeries, hospitalizations, accidents, or serious illnesses:
Date
Reason
__________ ___________________________________________________________
__________ ________________________________________________________________
__________ ________________________________________________________________
MEDICATIONS:
Prescription & non-prescription (vitamins, aspirin) used regularly:
Name
Reason
Frequency
___________________
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OCCUPATIONAL HISTORY
PLEASE CHECK YES IF YOU WILL BE WORKING UNDER THE FOLLOWING
CONDITIONS /EXPOSURES: (If YES, please note specifics about the exposure/condition?)
Yes
Description/Types
Animals/Animal tissue(species)
□
_____________________________________
Healthcare with patients
□
_____________________________________
Human blood/cell lines
□
_____________________________________
Recombinant DNA
□
_____________________________________
Infectious Agents
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_____________________________________
Chemical Agents
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_____________________________________
Noisy Environment
□
_____________________________________
Heavy Lifting (≥50 lbs.)
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_____________________________________
Use a Respirator
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_____________________________________
Other
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_____________________________________
U:EHC/clinical./forms/Health Clearance Questionnaire_2008
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University of Washington
CAMPUS HEALTH SERVICES
MEDICAL SURVEILLANCE HEALTH/WORK SCREENING QUESTIONNAIRE
What type of work have you done in the past? _____________________________________
___________________________________________________________________________
Have you ever had a work related illness or injury? _______________________________
What Type? ___________________________________________________________
During the past three years have you been off work due to a major illness or injury?
□ No If Yes, Explain: ___________________________________________________
Do you have any lifting limitations?
□ No
If Yes, Explain: __________________________________________________
NOTES:
___________________________________________________________________________
I certify that the above information is true to the best of my knowledge.
__________________________________
Employee signature
______________________
Date
PROVIDER SECTION ONLY:
Practitioner Signature:_________________________
U:EHC/clinical./forms/Health Clearance Questionnaire_2008
Date:_________________
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