EMPLOYEES HEALTH HISTORY FORM - Columbia Memorial Health

Name*

First Last

D.O.B.*

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

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