Preparation for Your Health Assessment
Location
Health Assessments are completed by our Employee Health Dept. which is located at 4435
Golf Acres Dr., Building P, Suite 300, Charlotte, NC 28208. Phone: 704-631-0200.
Please bring the following to your appointment:
•
Two forms of ID for completion of the I-9 Form (work authorization form). Refer to the
list of acceptable documents provided by your recruiter.
•
Photo ID for your drug screen.
•
Immunization Records for Measles, Mumps and Rubella (record of the vaccine or
titers). If you do not have these records, the vaccine will be provided at your health
assessment. Other records may be requested depending on your position.
•
A statement from your medical doctor if you have been under care for a chronic or
serious medical problem or have any work restrictions.
•
TST (Tuberculin Skin Test) If you have a record of negative tuberculin skin test within
the last 12 months, please bring it with you. If you have ever tested positive for
tuberculosis, a copy of the positive record and a chest x-ray is required.
•
Hepatitis B vaccine series if applicable to your job.
•
A list of prescription medications you are currently taking.
•
Prescription eyewear and/or contact lenses for the eye exam.
Important Information
•
Children: Please do not bring children to your health assessment as childcare is not
provided and CHS cannot be responsible for your child’s safety.
•
Deferral: If any required information is not provided at the time of your health
assessment, you will not be permitted to start work or attend orientation until the
information is brought to Employee Health. All items are due in Employee Health no
later than 5:00 p.m. on Thursday for Monday orientation and 5:00 p.m.
•
Your health assessment will be a minimum of 2 hours.
•
Your exam will be performed by one of our Employee Health nurses and will consist
of an overall physical check (you will not get undressed), eye exam, vital signs, urine
drug screen, tuberculin skin test (TST), Fit Testing for HEPA mask (if applicable) and
answering questions about your medical history.
•
If SBI/FBI fingerprinting is required for your job, this will be done during your
appointment. Your recruiter will notify Employee Health prior to your appointment if
this is required.
CAROLINAS HEALTHCARE SYSTEM
EMPLOYEE HEALTH
The Department of Labor requires that employers collect statistics. For this
purpose, please assist us by completing the following information which will
also ensure that your CHS benefits are set up properly.
Please circle an item in the multiple selection areas.
Date:________________
1.) Prefix: (Dr., Miss, Mr., Mrs., Ms.)
2.) First Name: _____________________________________
3.) Middle Name: ___________________________________
4.) Last Name: _____________________________________
5.) Mailing Address: ________________________________
6.) City: __________________________________________
7.) County: _______________________________________
8.) State: _________________________________________
9.) Zip Code: ______________________________________
10.) Primary Phone Number: __________________________
11.) Primary Phone Type: (Campus, Cellular, Dormitory, E-MAIL
Address, FAX, Home, Main, Other, Pager 1, Pager 2, Telex)
12.) Secondary Phone Number and Type: ________________
13.) Marital Status: __________________________________
14.) Date of Birth: ___________________________________
15.) Gender: (Male, Female)
16.) Social Security Number: __ __ __ - __ __ - __ __ __ __
17.) Ethnic Group: (Black, White, Hispanic, Asian, Pacific
Islander, American Indian, Alaskan Native)
18.) Military Status: (No Military Service, Not a Vietnam Era
Veteran, Other Eligible US Veteran, Pre Vietnam Era Veteran,
Post Vietnam Era Veteran, Retired military, Veteran/VA
Ineligible, Vietnam & Other Eligible Veteran, Vietnam Era
Veteran)
EMPLOYEE HEALTH USE ONLY- Place check beside completed items
Nurse________________
Fit Test_______________
Drug Screen __________
Finger Prints ___________
Psychological Test_______________
Physical Ability Test (PAT)___________ Other____________
CAROLINAS HEALTHCARE SYSTEM
EMPLOYEE HEALTH
Health History Form
Last Name: _____________________________ First Name: _______________________ SSN: _______-______-________
Date of Birth: ___/____/_____ Age:___________ Mailing Address: _____________________________________________
Preferred telephone contact: _______________________
Alternate telephone contact: __________________________
Orientation Date: ___/____/________ Recruiter: ______________________ Manager:______________________________
Job Title: _____________________________ Department: ____________________________ Facility: _________________
Please write the name and number of the physician we should contact in case of an emergency.
Name:
Specialty:
Phone:
Please check if you have now or had in the past any of the following medical conditions:
High Blood Pressure
 YES
 NO
Chicken Pox
 YES
 NO
Kidney Disease
 YES
 NO
Measles (Red Measles)
 YES
 NO
Heart Disease
 YES
 NO
Rubella (German measles)  YES
 NO
Diabetes
 YES
 NO
Mumps
 YES
 NO
Epilepsy
 YES
 NO
Hepatitis B
 YES
 NO
Lung Disease/Asthma
 YES
 NO
Hepatitis C
 YES
 NO
Any eczema/skin problems
 YES
 NO
Tetanus
 YES
 NO
Drug or Alcohol Problem
 YES
 NO
Rabies
 YES
 NO
Emotional Problems
 YES
 NO
Tuberculosis
 YES
 NO
Drug Therapy for TB
 YES
 NO
Immunity Problems (Lupus, HIV+, Chemotherapy) YES
NO
Chronic health conditions or concerns: _________________________________________________________________________
Please complete the following questions:
Please circle the reason you are completing this health screening:
new employee
student
Have you received treatment for any medical condition or injury in the past twelve (12) months? (for
example: surgery, illness, injuries, car accidents)
 Yes  No
If yes, describe:
Please list all surgeries and hospitalizations that you have had and approximate date:________________________________
______________________________________________________________________________________________________
Have you or do you currently have any of the following problems?
♦ Please circle current areas of pain, numbness or weakness: back shoulder neck arm wrist hand hip
 Yes
 No
 Yes
 No
 Yes
 No
knee ankle
Loss of balance or dizziness? ______________________________________________________
Do you wear a brace or use an appliance? ____________________________________________
Experience any breathing difficulties? _________________________________________________
Recent exposures to infectious diseases? _____________________________________________
Cumulative trauma disorders, such as tendonitis or carpal tunnel? __________________________
Have you ever had a back injury? If so, describe:________________________________________
Have you ever had lifting restrictions? Describe event, date:________________________________
_______________________________________________________________________________
Are you currently under the care of a healthcare provider (doctor, chiropractor, pain management, etc.)?
If yes, for what condition(s)?
Have you ever been involved in a Workers’ Compensation injury?
♦
♦
♦
♦
♦
♦
♦
CAROLINAS HEALTHCARE SYSTEM
EMPLOYEE HEALTH
Health History Form
HEALTH HISTORY FORM, page 2
Name: ____________________________________________
Were you exposed to hazards during previous work assignments? This could include chemicals/cleaning
 Yes
 No
compounds, radiation, dust or other respiratory hazards, excessive sun, infectious disease or bloodborne pathogen potential, etc.
If yes, please describe:
____________________________________________________________________
Have you suffered from heat intolerance? If so, describe event:________________________________
 Yes  No
__________________________________________________________________________________
 Yes  No
Have you had special hearing or vision testing because of previous work hazards? _________________
Based on your job description, do you currently have any physical or mental limitations and/or restrictions
that would keep you from performing the essential functions of your new position? (Examples would be:
limited lifting, bending, climbing, pushing, pulling, squatting, sitting, standing, walking, etc.)
 Yes  No
If yes, please describe or list the limitations:________________________________________________
___________________________________________________________________________________
Please list all medications you are currently taking. (Include vitamins, herbs, over-the-counter medications, pain medications
and narcotics or other controlled medications.)
Medication
Dosage/Frequency
Reason for Taking
Please list any allergies:
 Medication allergies:
 Food allergies:
 Latex, powder, vinyl, nitrile or dye allergies:
 Other allergies:
 No known allergies
HEALTH AND WELLNESS
SMOKING AND TOBACCO USE
Are you a current tobacco user?
 Yes  No If yes, what type tobacco do you use, and what amount do you use per day (including smokeless
tobacco)?________________________________________________________________________________
Are you currently in a smoking cessation program? _________________________________________
 Yes  No
If in a program, please give the program name(s):_____________________Date Started:____________
Are you currently or have you ever been on nicotine replacement therapy (NRT)? __________________
 Yes  No
If in the past, how long ago? __________________________________________________________
WEIGHT MANAGEMENT AND EXERCISE
Current Weight:
Current Height:
Please be sure to learn about LiveWell at Carolinas Healthcare for programs and incentives to enhance your health.
STRESS AND EMOTIONAL ISSUES
If you are not comfortable with your ability to manage your personal finances, or satisfied with your ability to manage your time well, or are not
content with your relationships with friends, families and co-workers, be sure to learn about the classes and offerings from our Employee
Assistance Program. There will be an EAP representative at New Employee Orientation, or you may find a link on the Carolinas Healthcare
System intranet, PeopleConnect.
CAROLINAS HEALTHCARE SYSTEM
EMPLOYEE HEALTH
Health History Form
HEALTH HISTORY FORM, page 3
Name: _____________________________________________
IMMUNIZATION AND TUBERCULOSIS TESTING HISTORY - for Employee Health Nurse only
 Yes  No
I have brought my vaccination history with me today.
Hepatitis B Virus vaccinations for employees in positions at risk for exposure to blood and body fluids
Circle completed Hepatitis B vaccines:  Series One (completed doses 1, 2, 3)  Series
 Yes  No
 N/A
Two (completed doses 4, 5, 6)
 Yes  No
 N/A
Tested for Hepatitis B surface Antibodies: Date: ____________ Result: ____________
 Yes  No
 N/A
Considered a “non responder” after 2nd series completed
 Yes  No
 N/A
Series started today:
 Yes  No
 N/A
Series resumed today:
 Yes  No
 N/A
Contraindications to vaccine: ________________________________________________
 Yes  No
 N/A
Refusal or declination form signed
Measles (Rubeola), Mumps, Rubella Vaccinations or Proven Immunity
 Yes  No
Have you had doctor-diagnosed disease for measles (rubeola), mumps, or rubella?
 Yes  No
Vaccine received today:  First Dose
 Second Dose
 Yes  No
Contraindications to vaccine: __________________________________________________________
 Yes  No
Draw blood sample for titer today
Varicella Disease/Vaccinations or Proven Immunity
 Yes  No
Did you have chicken pox as a child? Who can verify the disease? _____________________________
 Yes  No
Vaccine received today:  First Dose
 Second Dose
 Yes  No
Draw blood sample for titer today
Tetanus, Diphtheria, Pertussis Vaccine
 Yes  No
Have you had a Td or TDaP vaccination within the past ten (10) years? Date:___________________
 Yes  No
Do you know whether it was a Td or a TDaP vaccination booster?
 Yes  No
Vaccine received today
 Given Refused Vaccine:  Tetanus/Diphtheria (Td)
 Tetanus/Diphtheria/Pertussis (TDaP)
Meningococcal Vaccine
 Yes  No
Will you be working in the microbiology lab with culture specimens?
 Yes  No
Have you been vaccinated for meningococcal disease?
 Yes  No
Were you only vaccinated once? If so, was your vaccination greater than five years ago?
Influenza Vaccine (from September through March) Annual vaccination is strongly encouraged
 Yes  No
Do you take an annual influenza vaccination? This is offered free to all CHS employees annually.
 Yes  No
Have you received a flu vaccination for this year?
 Yes  No
Vaccination received today
Tuberculosis Testing History
Have you ever had a positive TB skin test (TST)? If yes, please provide the record of this positive skin
 Yes  No
test. If no test provided you will be tested again.
 Yes  No
If you had a positive TST in the past, did you have a chest x-ray? If so, please provide the record.
 Yes  No
If you had a positive TST in the past, did you take medication (like INH)? If so, for how long?________
 Yes  No
Have you ever had a BCG vaccination?
Do you have any current conditions that may cause you to have a weakened immune system, such as
 Yes  No
cancer, leukemia, chemotherapy, organ transplant history, HIV disease, steroid or prednisone therapy?
 Yes  No
Have you had any vaccinations in the past 4-6 weeks? (particularly MMR, varicella, or shingles)
 Yes  No
TST received today
Applicant Signature:___________________________________________
Date:_______________________________
CAROLINAS HEALTHCARE SYSTEM
EMPLOYEE HEALTH
Health History Form
HEALTH HISTORY FORM, page 4
PERSONAL HEALTH MEASUREMENTS- for Employee Health Nurse only
BP:______/ _______ Pulse: ________
Hearing:  WNL
Not WNL
Vision: glasses/contact lenses/no correction
Both eyes: 20/ _______ Left Eye: 20/_______ Right Eye: 20/_______
Have you had corrective surgery on your eyes:  Yes  No _________________________________________________
Color Blindness Testing:  WNL
Not WNL Notes:___________________________________________________
Nurse notes:
Employee Health Nurse:___________________________________________ Date:_______________________________