Highland Hospital / Secure / EHS Health Assessment EMPLOYEE HEALTH SERVICES place field "Lname" below Last Name place field "Fname" below First Name place field "Phone" below Phone place field "DOB" below Date of Birth place field "ID" below Employee ID place field "Dept" below Department place field "NewHealthProb" below Since your LAST Annual Health Update or in THE PAST YEAR: Have you had any NEW health problems? Yes No blank place field "IFYHealthProb" below Please List place field "NewMeds" below Have any NEW medications been prescribed to you? Yes No blank place field "IFYNewMeds" below Please List place field "Hospitalized" below Have you been hospitalized in the PAST YEAR? Yes No blank place field "IFYHospitalizedDate" below Date of Hospitalization place field "IFYHospitalized" below Please list reason place field "NewAllergies" below Have any NEW allergies developed including to medicine, latex, etc.? Yes No blank place field "IFYAllergies" below Please List place field "Disability" below Have you been out for a disability (such as surgery or illness)? Yes No blank place field "IFYDisability" below Please explain place field "Workinjury" below Have you had a work-related injury such as back or shoulder injury? Yes No blank place field "Condition" below Do you have any condition that would interfere with the ability to perform your job or be a risk to patients or other employees? Yes No blank place field "IFYCondition" below Please explain place field "Immunizations" below Have you had any immunizations from your provider or in the emergency room? Yes No blank place field "IFYImmunizationsUpload" below please provide copy of record- you can also email proof to HHEHS@URMC.ROCHESTER.EDU Please upload documentation Please select a file Delete file place field "Physexam" below Have you had a physical examination? Yes No blank place field "Gynexam" below For Females: Have you had a gynecological examination? Yes No blank place field "Eyeexam" below Have you had an eye examination by an ophthalmologist or optometrist? Yes No blank place field "IFYeyepresc" below Did you get a new eyewear prescription? Yes No blank place field "Hearing" below Have you noticed any changes in your hearing? Yes No blank place field "Sleeping" below Are you having difficulty sleeping? Yes No blank place field "Tobacco" below Have you smoked cigarettes or used any tobacco products in the past 30 days? Yes No blank place field "IFYSmokingsess" below Are you interested in Smoking Cessation information? Yes No blank place field "Drugabuse" below Have you been treated for substance abuse or addiction, including alcohol? Yes No blank place field "IFYDrugabuse" below Please explain place field "Weightchg" below Has your weight changed by more than 5-10lbs? Yes No blank place field "IFYWeightchg" below Please provide your current or recent weight, if known place field "Threatened" below Do you feel threatened in your work area? Yes No blank Does your work environment (equipment/room layout, isolation, clutter, etc.) contribute a risk to your safety? Yes No blank Please explain place field "Workviolence" below In the last year, have you been involved in an incident where you experienced workplace violence? (patient/co-worker/visitor violent towards you) Yes No If yes, did you fill out an incident report? Yes No place field "Incidentreportmade" below place field "Safetyrisk" below Have you tested POSITIVE for Tuberculosis in the past year? Yes No blank Do you have current or planned immunosuppression or take other immunosuppressive medications? Yes No place field "IFYSafetyrisk" below place field "TBPositive" below In the past year have you resided for more than 1month in a country with high TB rate? (Does Not Include: Australia, Canada, New Zealand, United States or Western/Northern Europe) Yes No blank place field "IFYTBPositive" below place field "residence" below In the past year have you had a known or suspected exposure to a person with ACTIVE TB at a time when you were NOT wearing proper N-95 protection? Yes No blank place field "Immuno" below place field "TBExpose" below Have you developed any of the following symptoms? (check all that apply) Cough Fever Night-Sweats Pink-Tinged Sputum Unexpected Weight Loss place field "IFYTBExpose" below Do you have any concerns or questions related to TB? Yes No blank place field "Symptoms" below Please explain place field "TBconcerns" below Do you have any other questions? Yes No blank place field "IFYTBConcerns" below Please explain place field "GeneralQ" below Employee Signature place field "IFYGeneralQ" below place field "EmployeeSig" below I certify that the information above is correct to the best of my knowledge, and I understand that my medical records are available upon request and completion of a release of information consent form. Today's Date: Our Privacy Policy$$submit-button$$
