Form 7k - Staff Health Form
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2NEW YORK CITY DEPARTMENT OF HEALTH AND MENTAL HYGIENE
BUREAU OF CHILD CARE
STAFF HEALTH FORM
Agency Stamp
Initial employment and every 2 years, a health examination is required for all teaching and non-teaching staff members, including
volunteers and students who regularly associate with children. Attach any additional documentation to this form.
/
/
/
/
Date of Employment
Date of Exam
(Last)
(First)
(Middle)
SEX
DATE
DATE OF BIRTH
F M
/
/
M M
(No.)
(Street)
(City/Boro)
(State)
(Zip)
TELEPHONE:
JOB TITLE
AREA EMPLOYED
AC (
)
PAST MEDICAL HISTORY
Please check YES or NO
Please explain any positive findings, list and explain any chronic
YES
NO
medications or therapies:
Hypertension
M
M
Heart Disease
M
M
Diabetes
M
M
Seizure Disorder
M
M
Chronic Lung Disease
M
M
Mental Illness
M
M
Alcohol Abuse
M
M
Substance Abuse
M
M
Physical Disabilities
M
M
Allergies
M
M
Hepatitis
M
M
OTHER (SPECIFY)
M
M
MEDICAL PROVIDER SECTION
PHYSICAL EXAM: (Please note any conditions or findings considered abnormal or requiring medical follow-up)
Height
Weight
/
Blood Pressure
TOBACCO USE
Current
Former
None
M
M
M
If current, referred for cessation services?
Yes
No
M
M
Counselled re: No Smoking
Yes
No
M
M
7K rev12_2016 r2
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