CN Brown Co - City of South Portland :: Home · Tennis elbow, golfers elbow, epicondylitis Bleeding...

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Patient Information Name: _____________________________________ Birth date ______________ Soc. Sec #_____________________ Address: _________________________________________________________________________________________ __________________________________________________________________________________________________ Home phone: ______________________________________ Cell Phone:____________________________________ Employer (Name, Address)________________________________________________________________________ _________________________________________________________________________________________________ Examination Consent _______________________________ has requested that we evaluate your ability to perform your job safely. This involves obtaining a general medical history and a physical examination including tasks such as lifting or pushing. Occasionally, additional testing or consultation with a specialist or the employer may be required to determine your ability to perform the tasks of the job. Be advised that this visit is for an evaluation only and not for treatment. After the evaluation, you will be notified of any identified problems that may require further medical care. You are responsible for arranging this with your own provider. For post-offer job placement assessments, we will send the employer a written opinion. This report is simply our opinion of your ability to safely perform the essential functions of your job. It will indicate whether you need accommodations or special job training in order to do this job. No medical information will be provided in that report unless you provide us with a written release to do so. For DOT examinations, a medical certificate, which complies with the requirements set forth in the Federal Motor Carrier Safety Regulations (49CFR) will be provided to the company. Some employers require the long DOT medical form, which contains your medical history and examination findings, be returned to them. (this is allowed by the regulations). Certain companies require the applicant/employee to complete special medical forms and return them to the company or another identified representative (e.g. their medical department). By signing below you are agreeing to allow us to do this. With all other companies, your medical information will not be released to your company without your written consent. By signing below, you are indicating that you understand the above information and consent to the medical examination and release of appropriate information to your employer/prospective employer. Signature: ________________________________________ Date: __________________ Witness: __________________________________________ Date: __________________

Transcript of CN Brown Co - City of South Portland :: Home · Tennis elbow, golfers elbow, epicondylitis Bleeding...

Page 1: CN Brown Co - City of South Portland :: Home · Tennis elbow, golfers elbow, epicondylitis Bleeding tendency Carpal tunnel syndrome Night sweats Hand numbness or tingling Unexplained

Patient Information

Name: _____________________________________ Birth date ______________ Soc. Sec #_____________________

Address: _________________________________________________________________________________________

__________________________________________________________________________________________________

Home phone: ______________________________________ Cell Phone:____________________________________

Employer (Name, Address)________________________________________________________________________

_________________________________________________________________________________________________

Examination Consent

_______________________________ has requested that we evaluate your ability to perform your job safely. This involves obtaining a general medical history and a physical examination including tasks such as lifting or pushing. Occasionally, additional testing or consultation with a specialist or the employer may be required to determine your ability to perform the tasks of the job. Be advised that this visit is for an evaluation only and not for treatment. After the evaluation, you will be notified of any identified problems that may require further medical care. You are responsible for arranging this with your own provider.

For post-offer job placement assessments, we will send the employer a written opinion. This report is simply our opinion of your ability to safely perform the essential functions of your job. It will indicate whether you need accommodations or special job training in order to do this job. No medical information will be provided in that report unless you provide us with a written release to do so.

For DOT examinations, a medical certificate, which complies with the requirements set forth in the Federal Motor Carrier Safety Regulations (49CFR) will be provided to the company. Some employers require the long DOT medical form, which contains your medical history and examination findings, be returned to them. (this is allowed by the regulations).

Certain companies require the applicant/employee to complete special medical forms and return them to the company or another identified representative (e.g. their medical department). By signing below you are agreeing to allow us to do this. With all other companies, your medical information will not be released to your company without your written consent.

By signing below, you are indicating that you understand the above information and consent to the medical examination and release of appropriate information to your employer/prospective employer.

Signature: ________________________________________ Date: __________________

Witness: __________________________________________ Date: __________________

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Medical History

For Post-Offer and Medical Surveillance Examinations

Name: First Middle Last Date of Birth: Company:

The following questionnaire will be used to determine the condition of your health. For job placement assessment candidates, this will be used to establish your baseline health status and determine appropriate job accommodations and assignments. For workers undergoing medical surveillance, it will allow the physician to identify whether any early or adverse health effects due to hazardous work exposures have developed so that appropriate treatment and/or safety recommendations can be made to you and your employer.

It is important that you be as complete as possible. Failure to provide important information regarding your health history with this examination may adversely affect your employment with this company.

Have you had or do you now Have: Yes No Have you had or do you now Have: Yes No

Ear, Nose, throat or sinus trouble Hay fever, hives or other allergies

Broken eardrum Latex or other substance related allergy

Eye trouble, eye injury or disease Multiple chemical sensitivity

Color blindness Bronchitis/pneumonia

Worn glasses Lung disease or emphysema

Trouble with mouth, gums or teeth Tuberculosis or a positive TB skin test

Difficulty swallowing Pleurisy or fluid in lungs

Hoarseness Frequent or persistent cough

Loss of sense of smell Coughing up blood

Ringing in ears Shortness of breath

Difficulty with hearing Stomach or intestinal problems

Heart trouble Ulcers/gastritis or GE reflux

High blood pressure Liver trouble, Hepatitis, or jaundice

Stroke Gall bladder trouble

Heart murmur Hemorrhoids

Heart attack, “MI” If yes, when?

Abdominal pain

High cholesterol Bowel trouble or change in bowl habits

Varicose veins Chronic nausea or vomiting

Phlebitis or blood clots Blood in bowel movements

Problems with circulation Persistent diarrhea or constipation

Chest Pain/angina Kidney, bladder or urinary problems

Leg pain with exertion/exercise Blood in urine

Cardiac stress test (treadmill test to check for heart disease), EKG, or other heart tests

Reproductive organ problems

Rapid heart beat Motor vehicle accident related injury

Asthma or wheezing Other significant trauma

Hernia Do you have any current work restrictions?

Illness due to indoor air pollution (e.g. mold, ventilation problems, dust, chemicals, etc.) If yes, list your symptoms:

Previous work injuries: Injury Company

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Have you had or do you now have? Yes No Have you had or do you now have? Yes No

Broken or fractured bones Frequent headaches or migraines

Dislocated or injured joints Cancer, cyst, growth or tumor

Back or neck herniated disc or surgery Sleep disturbance

Back trouble or back injury Fainting or dizzy spells

Recurrent or chronic back pain Tremors

Sciatica Balance or coordination problems

Arthritis, rheumatism, bursitis or gout Convulsions, fits or seizures

Fibromyalgia Numbness, tingling, or weakness

Tendinitis Anemia, blood problems or blood disease

Tennis elbow, golfers elbow, epicondylitis Bleeding tendency

Carpal tunnel syndrome Night sweats

Hand numbness or tingling Unexplained fever

Neck injury or whiplash Gland disorders

Injury to pelvis, hips, knees, ankles, feet Diabetes

Injury to the shoulders, arms hands Thyroid disease

Chronic muscle or joint pain. If yes, where?

Persistent fatigue

Other muscle or bone injury or conditions Increased thirst, hunger or urination

Nervous or mental problems Chronic infection, immune system disorder

Depression or anxiety Recent weight gain (> 10 lbs in past year)

Claustrophobia (fear of closed in spaces) Recent weight loss (> 10 lbs in past year)

Head injury or concussion Skin trouble, dermatitis or eczema

Loss of consciousness Alcohol or drug problems

Comments:

Medications: Prescription _______________________________________________________________________________________ Medical Marijuana Card______________________________________________________________________________ Over the counter, Herbal Remedies and Vitamins__________________________________________________________ How much caffeinated coffee/tea/cola/chocolate do you drink a day? ________________________________________ Medication/Food/Allergies____________________________________________________________________________ Vaccinations (reactions)______________________________________________________________________________ Immunizations: When was your last Tetanus Shot? ________ Unknown Have you ever had Hepatitis B Vaccination? Yes No If yes, did you complete the series B shots? Yes No Operations and hospitalizations, please list all including year: ________________________________________________ __________________________________________________________________________________________________

TOBACCO USE ALCOHOL USE

Please check off and answer all that apply to you: Please check off and answer all that apply to you:

Never smoked Former smoker

How often do you drink alcohol?

Quite smoking when?

Smoked how many years? When you drink, how many drinks, on average, do you have?

Approx. how many packs per day?

Current smoker

Age started smoking Have you ever been a problem drinker or treated for alcohol

Smoke how may packs per day? Overuse Yes No

Use other tobacco products

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Exercise: do you exercise on a regular basis? Yes No IF YES, how often and what type of exercise? ______________________ Family Medical History: (place an X in the appropriate box and the age when the condition developed)

Health condition Parent Grandparent Brother/Sister/Child Heart attack, MI, angina, Heart problems, bypass surgery

High cholesterol High blood pressure, hypertension Lung or breathing disease Cancer Other serious disease, conditions Occupational History:

Job Title Company Most recent job:

Previous job: Previous job: Previous job: Work Hazard and Environmental Exposure History: Please check off all categories of hazards/chemicals to which you have been exposed at work, home or with hobbies/recreation. Exposure Yes No Unknown Exposure Yes No Unknown Radiation Insecticides, herbicides, pesticides Contaminated water sources Noise Biological agents (animals, bacteria, viruses, molds, tuberculosis, etc.)

Solvents (e.g. benzene, carbon tetrachloride, glycol, ethers, ketones, carbon disulfide)

Petroleum based chemicals (e.g. asphalt and tar, coal tar, naphthalene, PCP’s, PBBs PAHs, petroleum distillates)

Plastics (e.g. vinyl, chloride, epoxy resins, styrene, acrylonitrile, fluorocarbons)

Blood born pathogens Have you ever had an exposure to blood or other potentially infectious materials (e.g. a needlestick, splash of blood to the eye)

Other Chemicals:

Metal, metal fumes (e.g. lead, arsenic, mercury, nickel other)

Inorganic dusts or powders (e.g. asbestos, fiberglass, silica coal, etc)

Chemotherapeutic agents (e.g. cancer drugs) Heavy physical labor, repetitive tasks, vibration

Tobacco Smoke – work or home Other hazards

Have you had any unexpectedly high exposures to hazards at the workplace recently or in the past? Yes No Did you become ill with these exposures? Yes No Do you have any known condition that prevents you from working nights or shift work? Yes No I certify I have completed my health history honestly and completely to the best of my knowledge. ___________________________________________________ ________________________________ Signature Date

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Patient NAME:___________________________________________ DOB:____________________

Clinician Examination VITAL SIGNS: BP_________________ Pulse _______ Respiration__________ Height_________ Weight___________________BMI__________

URINE DIP: Blood _____________ Protein _____________ Specific Gravity ________ Glucose _________ PH _______ Other__________

Vision: Contacts: Yes No Glasses: Yes No Glasses/contacts not available at the time of exam: Yes No Medical assistant: For eyeglass/contact wearers, perform test only with correction, unless the devices are unavailable. Near Vision Far Vision Satisfactory Unsatisfactory Corrected Uncorrected Corrected Uncorrected Fusion__________ __________________ Right 20/_____ 20/______ 20/______ 20/___________ Depth___________ __________________ Left 20/_____ 20/______ 20/______ 20/___________ Color____________ __________________ Both 20/_____ 20/______ 20/______ 20/___________ Peripheral ________ __________________

(X) Normal Organ System (x) Abnormal NE if not examined

Clinical Findings

1.General – Nutrition/body habitus, affect/personality

2. Eyes – Sclera, conjunctiva, pupils 7 fundi, extra ocular muscles

3. Head/Face

4. Ears – Canals, TMs conversational hearing

5. Nose

6. Mouth/throat – Dentition, or pharynx

7. Neck – Carotids, thyroid, lymph nodes

8. Lungs/Thorax – Shape, motion, lungs sounds

9. Heart – Size, rhythm/murmur/click

10. Abdomen – Scars, organs, masses, hernia, sounds, bruits

11. Vascular system – Varicose veins, pulses, edema

12. Rectal/prostate

13. Neurologic – reflexes, CNS, gait, sensation, balance, CNS, strength

14. Skin/nails – Tattoos, birth marks

15. Musculoskeletal – Posture, upper extremities, lower extremity, spine

16. Special tests – Tinels, Phalens, Finkelstein, Hyperflexion test, etc.

17. Pinch Strength/Grip Strength

Comments: Provider Signature:_____________________________________________________________Date:________________________________________________________