EMPLOYEES HEALTH HISTORY FORM - Columbia Memorial Health

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EMPLOYEES HEALTH HISTORY FORMCMH2020-07-31T12:42:07+00:00

EMPLOYEE HEALTH HISTORY FORM

Name*
First Last
D.O.B.*
Date Format: MM slash DD slash YYYY
Phone*
Position*
Dept/Office*
Email*
Select One*
- Employee
- Volunteer
- Contracted Employee
Medications
Have you had in the past year:
Back Problems*
- Yes
- No
Explain
Other Musculoskeletal issues (knees, shoulders, hands, etc)*
- Yes
- No
Explain
Liver or Kidney problems*
- Yes
- No
Explain
Hospitalized in past year*
- Yes
- No
Explain
Cardiac Problems (heart, high BP, A-Fib, CHF, chest Pain)*
- Yes
- No
Explain
Liver or Kidney problems*
- Yes
- No
Explain
Skin disease or boils, abscesses*
- Yes
- No
Explain
Severe Allergies (needing to carry an Epi-Pen)*
- Yes
- No
Explain
Thyroid Problems*
- Yes
- No
Explain
Anxiety or Depression or other mental health concerns*
- Yes
- No
Explain
Pregnancy*
- Yes
- No
Explain
Anemia or blood disorders*
- Yes
- No
Explain
Asthma or other respiratory chronic illness*
- Yes
- No
Explain
Neurologic Conditions: (such as Epilepsy, Seizures, MS, ALS)*
- Yes
- No
Explain
Have you ever had any of the following in your lifetime:
Tuberculosis or abnormal TB test*
- Yes
- No
When (ie. current, 1978..)
Traumatic Brain injury*
- Yes
- No
When (ie. current, 1978..)
Drug or Alcohol related problems*
- Yes
- No
When (ie. current, 1978..)
Other: (Select Correct Response)
Are you a current tobacco user?*
- Yes
- No
Would you like assistance in quitting*
- Yes
- No
- Not Applicable
Have you missed 3 days or more in a row of work for illness/injury in the past 12 months?*
- Yes
- No
If Yes, please explain
Admin Use Only
Provider Name Printed
Provider Signature
Date

Columbia Memorial Health (CMH) is the community’s hospital and healthcare network. Serving more than 100,000 residents in Columbia, Greene and Dutchess counties, CMH focuses on primary care, health education and advanced surgery. We are a multi-campus healthcare system including a 192-bed acute care hospital and 40 outlying primary and specialty care centers.

CONTACT INFORMATION

71 Prospect Ave, Hudson, NY 12534
518.828.7601

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EMPLOYEE HEALTH HISTORY FORM

Have you had in the past year:

Have you ever had any of the following in your lifetime:

Other: (Select Correct Response)

Admin Use Only