Occupational Health Record - Nova Scotia Health Authority

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OCCUPATIONAL HEALTH RECORD
The information in this Occupational Health Record provides baseline information and indications to ensure the health and
safety of healthcare workers and patients.
To be completed by applicant :
Last Name: ________________________ First: _______________________ Middle Name: ____________
Birth Date (YYYY/MM/DD): _____/___/____
Female
Male Health Card # ____________________
Address: ____________________________ City/Town: _________________ Postal Code: ___________
Phone (H): _______________ (C): _______________ E-mail (optional): ____________________________
Job Title: ____________________________________ Designation (FT, PT, Casual, Term): ____________
Department: __________________________________ Work Site: _________________________________
1. Have you been employed, volunteered or been a student with Nova Scotia Health Authority in the past (Eastern,
Northern, Central, or Western Zones)?
If yes, please name the facility: _____________________ What was your name at the time? ___________________
2. Do you have any of the following that could affect your performance in this job? If “Yes”, please explain.
Current and/or reoccurring (chronic) medical/health conditions:
Yes
No
_____________________________________________________________________________
Current medications:
Yes
No
_____________________________________________________________________________
Any medical conditions that make you prone to infections:
Yes
No
_____________________________________________________________________________
Past surgery:
Yes
No
_____________________________________________________________________________
Past and/or present musculoskeletal injuries/problems (back, shoulder, neck, hand, wrist, hip, knee, etc):
Yes
No
_____________________________________________________________________________
Past and/or present WCB claims:
Yes
No
_____________________________________________________________________________
Vision problems:
Yes
No
_____________________________________________________________________________
Hearing problems:
Yes
No
____________________________________________________________________________
Skin conditions:
Yes
No
____________________________________________________________________________
If skin condition is on your hands, does use of hand soap/sanitizers make this condition worse?
Yes
No
Rev May 2017
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