ANNUAL HEALTH ASSESSMENT

Name

Date of Birth

SEX
MF

Address

Phone

Emergency Contact Name/Relationship

Contact Phone

Please indicate if you are suffering from or have a history of the following conditions:

Diabetes
YesNo

Kidney Disease
YesNo

Heart Disease
YesNo

High Blood Pressure
YesNo

Arthritis
YesNo

Mental Illness
YesNo

Epilepsy/Convulsions
YesNo

Swelling in the Extremities
YesNo

Migraine headaches
YesNo

Fainting or Dizziness
YesNo

Back pain
YesNo

Pain during urination
YesNo

Change in bowel habits
YesNo

Increased thirst
YesNo

Persistent sores/lumps
YesNo

Infectious Diseases
YesNo

Cancer
YesNo

Any other physical disability
YesNo

Change in energy level
YesNo

Frequent cough
YesNo

ANNUAL TUBERCULOSIS RISK ASSESSMENT

The objective of the Annual TB Risk Assessment is to:

Identify latent tuberculosis infection (LTBI) or active TB; and comply with federal, state, and local regulations and guidelines.

1) Have you traveled (temporary or previously lived) for one month or more in a country with a high TB rate (i.e., any country other than Australia, Canada, New Zealand, the United States, and those in Western or Northern Europe)?
YesNo

2) Have you had close contact with someone who has had TB disease?
YesNo

3) Have you had close contact with someone who has been treated for Latent TB Infection?
YesNo

4) Have you had prior diagnosis of active TB or Latent TB Infection, or positive skin test or positive blood test for TB?
YesNo

If yes, have you been treated with medication for TB?
YesNo

OR, for a positive TB test?
YesNo

Persistent cough for 3+ weeks
YesNo

Coughing up blood
YesNo

Persistent shortness of breath
YesNo

Night sweats for no known reason
YesNo

Chest pain
YesNo

Unexplained weight loss
YesNo

Loss of appetite
YesNo

Hoarseness
YesNo

Unexplained fatigue for 3+ weeks
YesNo

Fever or chills for no known reason
YesNo

1) Do you smoke?
YesNo

2) Do you drink alcoholic beverages?
YesNo

If yes, how much?

3) Do you take depressants, stimulants, or narcotic drugs that alter your behavior?
YesNo

4) Do you take prescription medications?
YesNo

If yes, which medications do you take?

5) Do you have any allergies?
YesNo

If yes, what are you allergic to?

Name of your physician

Your physician Address:

I have read the above and declare that I have had no injury, illness, or ailment other than as specifically identified. I certify that I am not habituated or addicted to any depressants, stimulants, narcotic drugs, alcohol, or other substances that may alter my behavior

Form Date

Employee Signature