LOYOLA
PATIENT NAME ______________________________
UNIVERSITY
M.R. NUMBER. _______________________________
HEALTH SYSTEM
D.O.B.
______________________________________
EVALUATION HISTORY FORM
Loyola University Chicago
Occupational Health Services
Type of
Exam:
Preplacement
Return to Work
Disability
Workers’
Compensation
Transfer
International Service
Health Maintenance
Other (List Reason)
Separation/Retirement
Periodic
Medical Surveillance
•
•
Name
Social
Security No.
-
-
Address
Telephone
(
)
Sex:
Date of
Birth
Male
Female
Employer
Job Title
Private Physician’s Name
Address
Specialty
Telephone
Who should be contacted in case of an emergency?
Name
(
)
Relationship
Address
PAST MEDICAL HISTORY
Telephone
(Home)
(
)
Telephone
(Work)
(
)
(A)
When was your last complete physical exam:
(B)
Have you been told you have any medical problems?
(C)
Medications (List any used on a regular basis, include birth control medications and nonprescription drugs
such as vitamins, cold remedies, aspirin, etc. If none, so state.)
(D)
Do you use any prostheses, colostomy appliances, artificial limbs,
braces, etc.?
(E)
(F)
Hospitalizations/Operations/Accidents/Injuries (since last exam)?
None
No change since last exam
Date
Description
Have you ever received a transfusion of blood or blood products?
If yes, when:
Date:
No
No
Yes (please explain)
Yes (please explain)
Yes--please list date(s) & type(s)
No
Yes
EVALUATION HISTORY FORM
(G)
Page 2
No
Do you have, or have you ever had any allergies (food, medicine,
latex, other)?
If latex allergy, what type?
Localized rash
How has your latex allergy been diagnosed?
Yes (please list)
Generalized hives
asthma
nasal/eye symptoms
patch test
blood test
other
(H)
Do you have any physical limitations or restrictions which affect any of your activities at
home or work?
No
Yes (please list)
(I)
Communicable Diseases:
¾ Have you ever had:
No change since last exam
¾ Immunizations:
PAST MEDICAL HISTORY
DATE:
• Diphtheria/
Tetanus
• Measles (Rubeola)
No
Yes, Date:
• Mumps
• Rubella (German
Measles)
No
Yes, Date:
No
Yes, Date:
• Hepatitis B
• Chicken Pox
No
Yes, Date:
• Measles
• Hepatitis B
No
Yes, Date:
• Mumps
• Rubella
¾ Tuberculosis:
No
Have you ever had tuberculosis?
(J)
Last skin test date
RESULT:
Chest X-ray date
RESULT:
Yes
• Varicella
• Other
Reproductive:
¾ Have you and any partner:
• Had difficulty conceiving or been unable to conceive a pregnancy?
• Suffered a spontaneous abortion?
™ If YES, how many?
• Experienced a stillbirth child?
• Had a low birth weight child?
• Had a child with physical development or behavioral disabilities?
• Had a child with cancer?
FEMALE
¾ Do you have periods?
No … Yes
• If YES, are your periods regular?
¾
No … Yes
• If YES, how often?
No
No
Yes
Yes
No
No
No
No
Yes
Yes
Yes
Yes
MALE
Any difficulty with sexual
function?
No … Yes
• If YES, please explain:
• If YES, for how many days?
¾
Have you ever been pregnant?
No … Yes
• If YES, how many times?
• If YES, how many live births?
(K)
No
Do you have any hobbies?
Hobbies
Substances Used
(glue, paint, chemicals, etc.)
Yes (list below)
Physical Exposures
(noise, temperature exposures, etc.)
PAST MEDICAL HIST.
(L)
Travel
¾ Are you required to travel for your job?
No
Yes (explain
below)
¾
Have you traveled outside the U.S. in the last year?
No
Yes (explain
below)
¾
Have you ever been treated for an illness in another country or
treated for an illness you contracted in another country?
No
Yes (explain
below)
† No change since last exam
Age, or Age at Death
If deceased, cause
Other major health problems
Father
FAMILY HISTORY
Mother
Siblings
-Brothers/Sisters
Children
Spouse
Comments:
Marital Status:
† Single
† Married
† Divorced
† Separated
† Widowed
SOCIAL HISTORY
No. of Dependents at home:
Tobacco Use:
† Never
† Past age started
† Age stopped
† Present age started
Alcohol Intake:
† Beer
† Wine
† Spirits
† Cigarettes
† Cigars
† Pipe
#
#
#
/day
/day
/day
or
or
or
Any history of treatment?
† No † Yes, please describe
Have you ever used drugs or been treated for drug use?
† No † Yes, please describe
#
#
#
#
#
#
Packs/day
/day
Bowls/day
/week
/week
/week
EVALUATION HISTORY FORM
Page 4
Review of Systems:
Do you have any new or persistent symptoms or medical problems since last exam?
F No
If YES, complete the following and elaborate in the “Comments” section on page 7.
If NO, proceed to “Occupational History” on page 5.
NO YES
GENERAL
BONES/JOINTS
Night sweats or fever
Neck Injury
Recent weight loss/gain
Neck Pain
Blood or bone marrow disease
Back Injury
Bleed easily
Back Pain
Anemia
Joint Injury/Pain
Swollen glands
Muscle Injury/Pain
Problems with immune system
Arthritis
Cancer
Broken Bones
F Yes
NO
YES
Hay fever
MEDICAL HISTORY
NERVES
SKIN
Convulsions/Fits/Seizures (Epilepsy)
Change in any wart or mole
Head Injury
Skin diseases
Memory Loss
¾
Difficulty Concentrating
If YES, list here:
Numbness/Tingling
Carpal Tunnel Syndrome
EYES
Fainting/Dizzy Spells
Wear eyeglasses?
Headaches
¾
If YES, please specify:
□Reading
□ Distance
□Contact Lenses: □
□ Left Eye Only
Both Eyes
□ Right Eye Only
Paralysis
Trouble Sleeping
Stress
Color Blindness
Depression
Cataracts
Any Mental Disorder
Glaucoma
Vision Problems
LUNGS
¾
Shortness of Breath
If YES, please specify:
Any Lung Trouble
¾
If YES, please specify:
EAR, NOSE, THROAT
Hearing Problems
Asthma
Noise in Ears
Bronchitis
Balance Problems
Pneumonia
Sinus Problems
Tuberculosis
Mouth Sores
Persistent Cough
Change in Voice
Cough up blood
Hoarseness
Exposed to Second Hand Smoke
Difficulty Swallowing
¾
If YES, please specify where:
F Home
ENDOCRINE
Diabetes
Thyroid Problems
¾
If YES, please specify:
F Work
EVALUATION HISTORY FORM
Page 5
NO
YES
NO
HEART
GENITOURINARY
Heart Problem
Blood in Urine
¾
Kidney Problems
If YES, please specify:
YES
Reproductive Problems
Chest Pain
Bladder or Reproductive Infections
Heart Failure
Prostate Problems
Rheumatic Fever
Irregular Heart Beat
High Blood Pressure
VASCULAR
Swollen Ankles
Stroke/Blood Clot
ABDOMEN
Cramps in Legs when Walking
Varicose Veins
MEDICAL HISTORY
Ulcers
Change in Bowel Habits
OTHER
Hernia
Please explain any medical problems not listed
above:
Nausea/Vomiting
Pain in Abdomen
Liver Disease
Hepatitis/Jaundice
Blood in Stools
Black Tarry Stools
Vomiting of Blood
OCCUPATIONAL HISTORY
EXAMINER’S COMMENTS:
Usual Occupation
Present Job
No. of Yrs. At Present
Occupation:
NO
Have you been injured at work in the past year?
¾
If YES, give date and describe:
Did you receive Workers’ Compensation?
Date:
YES
EMPLOYMENTHISTORY
EVALUATION HISTORY FORM
Page 6
List each job in reverse chronological order (include military service and foreign posts):
Date
Position / Job Duties
Company Name
From
To
NO
I)
YES
Have you ever worked in or around the following?
¾ Chemical Plant
¾ Construction Site
¾ Cotton, flax, or hemp mill
NO
YES
V) Have you ever suffered any
known health effects from
any exposure?
¾ If YES, explain:
¾ Electronics Plant
¾ Farm
OCCUPATIONAL EXPOSURE QUESTIONNAIRE
¾ Fiber Mill
VI) Do you have any
environmental allergies (hay
fever, etc.)?
¾ Foundry
¾ Mine
¾ If YES, explain:
¾ Outdoor Areas
¾ Paper / Lumber Mill
¾ Refinery
¾ Shipyard
VII) Do you have any history of
insect or tick bites?
¾
If YES, explain:
¾ Dusty Jobs
¾ Other job sites with hazardous
exposure
•
If YES, please list:
VIII) Have you ever used or been exposed to the
following chemicals or conditions:
¾ Arsenic
¾ Asbestos
¾ Benzene
¾ Beryllium
II) Have you ever received medical
surveillance, periodic check-ups or
tests as part of a prior job?
¾
If YES, explain:
¾ Cadmium
¾ Carbon Tetrachloride
¾ Changes in temperature/
temp extremes
¾ Chromates
III) Have you ever been hurt or injured
in previous jobs?
¾
If YES, explain:
¾ Dust
¾ Fluorides
¾ Lead
¾ Loud Noises
IV) Have you ever left a job for health
reasons?
¾ Mercury / Other Heavy
Metal
¾
¾ Lasers
If YES, explain:
¾ Pesticides
EVALUATION HISTORY FORM
Page 7
NO
VIII (Cont’d)
OCCUPATIONAL EXPOSURE
¾ Phenols
YES
NO
YES
IX) Have you recently used any of the following
personal protective equipment on your
prior job?
¾ Phosgene
¾ Plastics
¾ Respirator
¾ PVC’s
¾ Hearing Protectors
¾ Radioactive Materials
¾ Gloves
¾ Repetitive Motion / Vibration
¾ Protective Clothing/Shoes
¾ Solvents / Degreasers
¾ Safety Glasses/
Goggles/Shield
¾ Spray Painting
¾ Others (list):
¾ Trichloroethylene
¾ Welding / Soldering
•
¾ Others (list):
•
•
•
•
•
•
•
COMMENTS
Comments and/or explanations of Positive or Abnormal Responses:
Applicant/Employee: I certify that the above information is true and correct to the best of my
knowledge:
Signature _______________________________________________________________ Date _________________________________
Medical Reviewer’s Signature: ______________________________________________ Date _________________________________
______________________________________________________________________________________________________________
MEDICAL EVALUATION
Physically qualified to perform essential functions included in the job description
Without limitation/restriction/accommodation
With limitation/restriction/accommodation
Describe: _______________________________________________
_______________________________________________________________________________________________________
Not physically qualified to perform essential functions included in the job description.
Unable to determine if physically qualified to perform essential functions included in the job description.
Reason: _______________________________________________________________________________________________
NP/OHS RN Signature ____________________________________________________