Auhsp Medical Evaluation Form - Cornell University Page 3
ADVERTISEMENT
1
2
3
45. Have you had any skin problems caused or exacerbated by your work activities?
No
Yes
Don’t know
If yes, please describe the skin problem
Have you had this skin problem within the past 12 months?
No
Yes
If yes, what is the current severity of your skin problem?
Mild
Moderate
Severe
What skin problem treatment are you currently using?
C. INCREASED RISKS
1. PREGNANCY RISK
Some research-related or animal biohazards have adverse effects on pregnancy.
Are you pregnant or planning to become pregnant in the next year?
No
Yes
Not Applicable
2. COMPROMISED IMMUNITY RISK
Some research-related or animal biohazards may create an increased risk for individuals who are
immunocompromised.
Are you immunocompromised due to certain diseases (such as cancer, lupus, rheumatoid arthritis, HIV)
and/or their treatment (such as steroids, radiation therapy, chemotherapy)?
No
Yes
3. SHEEP EXPOSURE RISK
Exposure to sheep may create an increased risk for individuals with certain heart conditions.
Do you have exposure to sheep AND a history of heart valve disease, heart murmur,
or heart disease present from birth?
No
Yes
D. INJURY/ILLNESS DURING PAST 12 MONTHS
Symptoms of some research-related or animal-related illnesses may not be immediately recognized.
Please check any of the following problems you have had in the past 12 months:
Chronic cough
Other muscle/joint injury
Infection from an animal
Abdominal cramping
Fatigue
Needlestick/laceration/ puncture wound
Diarrhea
Weight loss
Chemical exposure
Hand/wrist pain
Fever
Other
Back pain/injury
Animal bite/scratch
No injury/illness during the past 12 months
Please describe problem and treatment:
E. WORK-RELATED HEALTH CONCERNS
Do you have any work-related health concerns that you would like to discuss with an Occupational Medicine health care
professional?
No
Yes
A Gannett Occupational Medicine health care professional will contact you to discuss these concerns. Please indicate the
best time to contact you.
To the best of my knowledge, the information included herein is true.
/_ /_
Signature of Individual Completing This Form
Date
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical