87 Washington St Rensselaer NY 12144


EMPLOYEE ANNUAL HEALTH QUESTIONNAIRE and TB assessment

 

Employee Name:   Last Four Digit of SSN:  

Date of Birth: - - Example: 02 23 1983                       Today's Date:


Part A Since the employee’s last health screening, does the employee state that they have:

 Yes    No 1. Had any significant illnesses or hospitalizations?
    If yes, please provide details
 Yes     No 2. Had Surgery in the past year?
    If yes, please provide details
 Yes  No    3. Had any injuries?
    If yes, please provide details
 Yes  No     4. Had any changes in pre-existing health problems?
    If yes, please provide details
Yes No  5. Developed any new health problems?
    If yes, please provide details
 Yes    No      6. Seen a physician for anything besides a routine physical or minor illness?
    If yes, please provide details
 Yes  No     7. Started on any new medications?
    If yes, please provide details
 Yes  No      8. Currently taking any prescription medications or over the counter medications?
    If yes, please provide details
 Yes  No      9. Had any complaints of shortness of breath, cough or chest pain?
    If yes, please provide details
 Yes   No      10. Had any complaints of fever or night sweats?
    If yes, please provide details
 Yes    No    11. Know of, or believe there is any health reason why they cannot or should not provide direct patient care?
    If yes, please provide details
 Yes   No    12. Had any unresolved illnesses or medical conditions?
    If yes, please provide details
 Yes   No  13. Do they have a problem with habituation or addiction to alcohol, depressants, stimulants, narcotics or other substances that may alter their behavior?
    If yes, please provide details


TB assessment:

Timeframe for all questions is since the employee’s last TB assessment or test.

 Part B Does the employee state that they notice any of the following:

1. Unexplained fevers: yes no 2. Night sweats? yes no
3. Unintentional Weight Loss? yes no 4. Cough for 3 or more weeks? yes no
5. Loss of appetite? yes no 6. Hoarseness? yes no
7. Bloody Sputum? yes no 8. Chest Pain? yes no
9. Fatigue? yes no 10. Have you completed INH Therapy? yes no
11. History of temporary or permanent residence or travel (for >30 days) in a country with a high TB rate (i.e. any country other than Australia, Canada, New Zealand, the United States, England/UK, the Republic of Ireland, Belgium, the Netherlands, Luxembourg, France, Germany, Denmark, Norway, Sweden, and Iceland. Finland, Southern Germany, Switzerland, and Austria)   yes no 12. Current or planned immunosuppression, including human immunodeficiency virus infection, receipt of an organ transplant, treatment with an TNF-alpha antagonist (e.g., infliximab, etanercept, or other), chronic steroids (equivalent of prednisone >15mg/day for >1 month), or other immunosuppressive medication like chemotherapy;
yes no
13. Close contact with someone who has had TB disease yes no

Give details below for any  "YES" answers: