Patient Health History Form Page 2
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2Occupational Health Services
3101 Shippers Road, Suite 101
Vestal, NY 13850
607-251-2170
Fax 607-251-2012
Do you take any prescription medications on a regular basis? ( ) Yes ( ) No
If yes, please list_______________________________________________________________________
_____________________________________________________________________________________
Do you take any over-the counter medications on a regular basis? ( ) Yes ( ) No
If yes, please list _______________________________________________________________________
Are you allergic to any foods, medications, or environmental items? ( ) Yes ( ) No
If yes, please list _______________________________________________________________________
Are you addicted to, or habitually use (prescription r otherwise), depressants, stimulants, narcotics,
alcohol, or other substances that could alter your behavior? ( ) No ( ) Yes ________________________
Do you smoke? ( ) No ( ) Yes- How much? __________________ How long?______________________
Are you a former smoker? ( ) No ( ) Yes- When did you quit?__________________________________
Do you drink alcohol? ( ) No ( ) Yes- How much?____________________ How often?_______________
Do you use recreational drugs? ( ) Yes ( ) No
Do you participate in a regular exercise program? __________________________________________
Do you wear a seatbelt? ( ) Yes ( ) No
Do you have working smoke alarms and carbon monoxide detector? ( ) Yes ( ) No
What are your hobbies? _________________________________________________________________
Have you ever, currently or in the past, had a work related injury or illness? ( ) Yes ( ) No
If yes, please explain: ___________________________________________________________________
Have you ever, in the past or currently, collected disability or worker’s compensation? ( ) Yes ( ) No
If yes, explain: _________________________________________________________________________
When was your last tetanus shot? _________________________________________
Occupational work history:
Employer
Date
Job description
1.___________________________________________________________________________________
2.___________________________________________________________________________________
3.___________________________________________________________________________________
The following statement to be signed by the applicant: I, the undersigned, hereby certify that all the
information I have furnished on this form is true and correct. I willingly submit to any required tests
necessary to complete the examination.
Applicant signature:_______________________________________ Date: ________________________
Reviewed by Occupational Health Staff: ___________________________________ Date: ____________
Provider Signature: ____________________________________________________ Date: ___________
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