Preplacement Medical/physical Assessment Form - Howard County General Hospital -
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3PREPLACEMENT MEDICAL/PHYSICAL ASSESSMENT
Date:________________________ Position Applied For:____________________________ SS# XXX-XX-_________
__________________________
_____________________
_____
Age____
Sex____
DOB:______________
Last Name
First
Initial
Address:__________________________________________ City/State/Zip___________________________________
Home Phone:______________________________________ Cell Phone:_____________________________________
Occupational Health History : Have you ever worked with materials that irritated your nose, eyes, lungs, and chest?
Did these materials/chemicals make you feel “High” or lightheaded, or nauseated? If yes, explain:
Have you worked around:
Yes
No
Yes
No
Dust
___
___
Anti-Neoplastic Drugs
___
___
Solvents
___
___
Radiation
___
___
Ethylene Oxide
___
___
Formaldehyde
___
___
Lasers
___
___
Anesthetic Gases
___
___
If any yes answers to above questions, please elaborate:
_______________________________________________________________________________________________
Have you ever worked with asbestos or silica? ___________ Where? _____________________When? ___________
Health History:
In case of emergency notify: _________________________________ __________________ _________________
Name
Phone #
Relationship
Who is your personal physician? _____________________________
__________________
Name
Phone #
Are you allergic to any medications? _______
If yes what?_______________________________________________
Are you taking any medications? _______
If yes, what? _____________________________________________
_______________________________________________________________________________________________
Immunization History: Please mark if you have had these immunizations. Enter the year when you were last given
the “shot” or test.
Year
Tetanus
_____
Hepatitis B Series
_____ (Titer Available? ______)
MMR
_____ (Titer Available? ______)
Varicella
_____ (Titer Available? ______)
BCG
_____
Tuberculin Skin Test
_____
(Results Available? ______)
Chest X-Ray
_____ (Results Available? ______)
Seasonal Flu Vaccine
_____
Smoking History:
Have you ever smoked cigarettes?
No ______
Yes ______
How long? ______
Do you still smoke?
No ______
Yes ______
How much? ______
Do you exercise regularly?
Yes______
No______
Do you wear seat belts in the car?
Yes______
No______
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