VIVARIUM OCCUPATIONAL HEALTH PROGRAM
BASIC HEALTH HISTORY FORM
DIRECTIONS: Complete the form online. Print the completed form on standard 8.5 X 11 paper, then sign and
date. Make a copy of the completed form for your own files.
SUBMITTAL: The form must be sent either by fax or by mail as follows:
FAX # : ATTN: Dr. Lawrence Raymond – Occupational Physician: (704) 631-1202 (secure line)
MAIL:
UNC Charlotte Occupational Health Program - CONFIDENTIAL
c/o Dr. Lawrence Raymond
4135 South Stream Boulevard
Charlotte, NC 28217
If you have questions about this form, contact the Office of Research Compliance at (704) 687-1872 or at uncciacuc@uncc.edu. If you have health related questions, contact Dr. Lawrence W. Raymond, Occupational Physician at
(704) 631-1264.
PERSONAL INFORMATION:
Date Submitted:
Last Name:
First Name:
Middle Initial:
UNCC ID 800#:
Email Address:
Lab Affiliation:
Department:
Bldg/Room:
Lab Phone #:
Job Title:
Date Hired:
Home Address and telephone:
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Date of Birth:
Sex:
Select
Person to Contact in Case of Emergency:
Relationship to You:
Phone: (HOME):
(MOBILE):
Personal Physician:
Phone:
May we contact your personal physician for medical information if needed?
Yes
A. NATURE OF EXPOSURE (Check all statements applicable to your work situation)
In the scope of my work, I will:
Participate in an animal study but will not handle animals or enter into animal housing areas.
Work in rooms or areas where vertebrate animals are housed, but I will not handle animals or their fluids or tissues.
Duration of animal exposure (hours/week):
Work in animal areas and handle vertebrate animals or their fluids or tissues.
Duration of animal exposure (hours/week):
Provide routine veterinary care or husbandry to animals.
Work in the field.
B. SPECIFIC RISK CATEGORIES (Check all statements that apply to you)
1. Animal Hazard Exposure
Bite tendency moderate to high (e.g. rodents, wild mammals)
Scratch tendency moderate to high (e.g., rabbits, wild mammals, raptors)
Allergy potential moderate to high (e.g., rats, mice, birds)
Zoonotic disease potential moderate to high
OR
Not applicable [if you check this box, do not check any others on this question]
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2. Animal Product Hazard Exposure
Feces
Urine
Blood
Fresh carcass or tissue
OR
Not applicable [if you check this box, do not check any others on this question]
3. Radiation Exposure(when working with animals or in the animal housing areas)
Research Nuclides--radioactive materials
99m
Tc only
X-ray only
Lasers
List class:
Other:
List:
OR
Not applicable [if you check this box, do not check any others on this question]
4. Biological Hazard Exposure(hazard to humans when working with animals or in the animal housing areas and/or to
other animals in the animal housing areas)
Categories:
RDNA work that comes under the NIH Guidelines (i.e., requires approval minimally at the IBC level)
BSL-1 organism
BSL-2 organism
Agents: Provide name(s):
Viruses:
Bacteria:
Yeasts:
Molds:
Protozoa:
Other:
OR
Not applicable [if you check this box, do not check any others on this question]
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5. Chemical/Laboratory Exposure (When working with animals or in animal housing areas)
Anesthetic gases
Compressed gases in tanks
Controlled drugs
Adjuvants
Toxins (Specify below)
Carcinogens (e.g. alfatoxins, benzene, ethyl oxide).
Please list:
Mutagens/Teratogens (e.g., cyclophosphamide, thalidomide, lead mercury)
Please list:
Other toxins
Please list:
Flammables
Solvents (e.g., acetone, diethyl ether, methyl alcohol)
Please list:
C. ALLERGIES: (Check all appropriate boxes)
Animal
Dust
Chemical
Foods
Medication
Plant
Pollen
Venom
Specific Allergies:
D. IMMUNIZATIONS: (Check immunizations you have received and indicate MOST RECENT YEAR
of that immunization): NOTE: Only the tetanus immunization date is required.
Diphtheria
Mumps
Rubella
Hepatitis B
Pertussis
Tetanus
Influenza
Polio
Typhoid
Measles
Rabies
Smallpox
E. HEALTH HISTORY
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State Your Main Health Concern(s):
Medications
Past Hospitalizations (Date, Why):
Cause/Duration of Sick Leave (past 5 years):
Past/Present Work Restrictions:
Other Diagnoses:
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F. CURRENT HEALTH STATUS (Check all that apply.):
Allergy Injection
Therapy
Asthma
Anemia
Appetite Loss
Arthritis
Back Injury
Bloating/Gas
Blood in Stool
Blood in Urine
Bruising
Cough
Diabetes
Dizziness
Drainage
Dribbling/Hesitancy
Earache
Eye Pain, Blurring
Fainting
Fatigue/Weakness
Fever
Focal
Numbness/Weakness
Headache
Frequent Urination
Tumor
Hay Fever
Hearing Loss
Heart Trouble
Heartburn
Hernia
High Blood Pressure
Voice Hoarseness
Joint Swelling
Loose Stools
Loss of Balance
Immune
Deficiency
Nausea/ Pain
New/Changing Moles
Nosebleeds
Rash
Ringing Ears
Sickle Cell Anemia
Sinus Congestion
Sinusitis
Sore Throats
Speech Change
Problem swallowing
Swollen Glands
Upset Stomach
Weight Loss
Other:
G. OCCUPATIONALINFORMATION
List Titles of Jobs Held More Than 6 Months (if applicable):
Check Chemical/Physical Agents Used/Exposures:
Animal Danders
Mercury
Sun (>2hr/day)
Arsenic
Commercial
Diving
Cotton Dust
Methanol
Welding Fumes
Asbestos
Formaldehyde
Noise
Wood Dust
Benzene
Lasers
Pesticides
X-rays
Chlorinated
Hydrocarbons
Lead
Radioisotopes
Solvents (name if known):
Other Chemical Exposures:
Protective Equipment Used:
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Eyewear
Safety Shoes
Hearing Protection
Brand / Type of Respirator Used (if applicable):
Other:
Comments:
CAUTION:Some infectious diseases, including certain Zoonoses, are known to affect the fetus adversely. If you
or someone in your household is pregnant or planning to become pregnant, please discuss your risk
level with a healthcare professional prior to working with animals.
I hereby agree to immediately inform the Occupational Physician of any changes in the above history.
Signature:
Date:
Reset
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