Non-Employee Pre-Placement Health Examination
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1
2NEW YORK CITY HEALTH AND HOSPITALS CORPORATION
SOUTH MANHATTAN HEALTH CARE NETWORK
Bellevue Hospital Center
Occupational Health Service
NON-EMPLOYEE PRE-PLACEMENT HEALTH EXAMINATION
BY PRIVATE PHYSICIAN
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Name__________________________________________________________________________
Last
First
Date of Birth___________ Title_____________ Dept.____________ Work Location__________
TO PHYSICIAN: A pre-placement health examination is required for the above-
1.
named person. Please enter details of all requested information. LABORATORY
Incomplete or illegible information may be
REPORTS MUST BE ATTACHED.
rejected
. Thank you.
Medical History:
2.
Any major illness or health impairment________________________________________________
Hospitalization/Serious injury________________________________________________________
Allergy__________________________________________________________________________
Medication currently being taken:_____________________________________________________
Physical Examination (notate all spaces; draw-through lines not acceptable):
3.
T_________ P________
R________ BP__________ Hgt___________ Wgt_________
Gen_________________ HEENT____________________ Neck______________________
Lungs________________ Heart_________________ Abd______________ Ext_________
Musculoskeletal________________________ Neuro________________________________
4.
Two (2) PPD Tests (Mantoux) or one (1) Interferon Gamma Release Assay (e.g. Quantiferon) required:
PPD Test 1 Date injected:_________ Date read:___________(within last 12 months) Induration:_______ (mm)
(mm/dd/yy)
(mm/dd/yy)
PPD Test 2 Date injected:_________ Date read:____________(within last 3 months) Induration:_______ (mm)
(mm/dd/yy)
(mm/dd/yy)
If PPD positive, what was the earliest date of positive PPD?________________ History of BCG? YES____ NO____ Date_________
Was Tb prophylaxis taken?
NO ____ YES _______ What medication?_____________________________ How long?___________
In your opinion what caused positive PPD?_________________________________________________________________________
Date:_________ Result:_____________
Quantiferon
(or other IGRA within last 3 months):
(report must be attached)
(mm/dd/yy)
Chest x-ray report must be attached.
5. Chest X-Ray
(for positive PPD or positive IGRA)
6. Rubella
OR
antibody titer:_________ Laboratory report must be attached
vaccine date:_________________
(mm/dd/yy)
7. Rubeola
OR
antibody titer:___________ Laboratory report must be attached.
2 doses of live vaccine dates: (1)______________________ (2)_____________________
(mm/dd/yy)
(mm/dd/yy)
8. Mumps
OR
antibody titer:____________ Laboratory report must be attached.
2 doses of live vaccine dates: (1)______________________ (2)_____________________
(mm/dd/yy)
(mm/dd/yy)
Revised January 7, 2015
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