Name: (First, MI, Last) � M � F DOB:

Social Security No.:

Position/Department:

Address:

Phone No.:

PERSONAL HEALTH HISTORY

LATEX ALLERGY: □ YES □ NO If yes, type of reaction:

When first occurred: Under treatment:

ALLERGIES TO MEDICATIONS OR OTHER AGENTS Type of Reaction

CURRENT MEDICATIONS (Name, Strength, Frequency): □ NONE

1. 2.

3. 4.

5. 6.

HOSPITALIZATIONS/SURGERIES □ NONE

Year Reason Year Reason

Have you ever had any of the following OR received medical treatment for? (Check all that apply)

□ NONE

□ Heart Attack □ Asthma □ Anxiety □ Hepatitis

□ Stroke □ Epilepsy □ Depression □ Rubella (German)

□ High Blood Pressure □ Diabetes □ Cancer □ Measles (Red)

□ Kidney Disease □ Bleeding Disorder □ Multiple Sclerosis □ Chickenpox

□ Emphysema □ Angina/Chest Pain □ Mumps □ HIV/AIDS

□ Alcohol or Drug Dependence/Abuse □ Tuberculosis

List any other medical condition not listed above:

MEDICAL HISTORY QUESTIONNAIRE

TUBERCULOSIS: Have you ever had a positive TB skin test or Blood Test (IGRA: Quantiferon or T-Spot)? □ YES □ NO

If yes, provide date: Have you had BCG? □ YES □ NO

If yes, provide date:

Date of most recent Chest X-ray:

Chest X-ray result:

Have you ever had an injury to any of the following body part(s)? (Check all that apply) □ NONE

□ Back □ Shoulder □ Knee □ Wrist

□ Hand/Finger □ Neck □ Ankle □ Head

□ Hip □ Other (specify):

Please provide date/details of each injury:

IMMUNIZATION HISTORY

Tetanus/Diphteria □ Yes □ No Date: Varicella (Chickenpox) □ Yes □ No Date:

Hepatitis A □ Yes □ No Date: Pneumococcal □ Yes □ No Date:

Hepatitis B □ Yes □ No Date: Measles♦Mumps♦Rubella (MMR) □ Yes □ No Date:

Other □ Yes □ No (specify) Date:

SOCIAL HISTORY

TOBACCO

Do you currently use tobacco? □ Yes □ No

How many years? How many packs per day?

Chew # per day Pipe per day Cigars per day

If you previously smoked, when did you quit?

I certify that the statements on this form are true and complete to the best of my knowledge. I understand that any misstatement or omission on this medical history questionnaire is cause for termination of my employment. Should I be referred to a Physician for further consultation I understand my employment offer will be suspended pending final results and expenses are my responsibility.

__________________________ ________________________ Signature Date OCCUPATIONAL HEALTH NOTES: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Reviewed by: _____________________________ Date:________________

VACCINE PREVENTABLE DISEASE POLICY

Vaccination or Immunity Attestation

Section 1: (complete where applicable)

PRINT CLEARLY Name: (Last) _____________________________________ (First) _________________________________________

MSO or Employee or Volunteer Number: ______________________ Student’s/Contractor’s Affiliation: _________________ ___

Status: (circle ONLY one) Physician/AHP Employee Contractor Student Volunteer Resident Fellow Other

(Credentialed Clinicians ONLY) Circle all Memorial Hermann location(s) where you have, or will have privileges:

TMC Memorial City Greater Heights Sugar Land Southwest Southeast Northeast Katy TIRR The Woodlands Pearland Cypress

Other Location not listed: __________________________________________

Section 2: (complete all questions)

1. Hepatitis B: Have you had one series of Hep B vaccine and a positive Hep B serum antibody, or two series of Hepatitis B antibody (6 total vaccinations)?

2. MMR (Measles, Mumps, and Rubella): Have you had two MM vaccinations and one Rubella vaccination or had a positive titer for each?

3. Varicella: Have you ever had two doses of Varicella vaccination or pne dose of Zoster vaccine or had a positive

serum antibody Varicella titer?

4. Tdap/Td (Tetanus, Diphtheria, Pertussis): Have you had at least one vaccination that included Pertussis and

that vaccination was within the last 10 years?

5. Influenza: Have you had a seasonal flu immunization for the current influenza season? (Oct-Mar)

6. Are you at risk for another vaccine preventable disease, not listed above?

7. Are you aware if you had a non-response to a vaccine or if you have no immunity to any disease listed?

Please provide details for no immunity: _________________________________________________________

8. Are you currently registered with the state of Texas immunization database (ImmTrac)?

In order to comply with the Texas state law each Health Care Professional must provide to Memorial Hermann any one or combination of four proof, or exception options: (a) Immunization record (b) titer indicating immunity OR (c) request and exception (religious, medical, OR reason of conscience) to the vaccine preventable disease policy (please review policy for requirements if you select this option) OR (d) if you answered “YES” to questions 1-5 above no further action may be necessary. If you marked “NO” to any question above you may report to any Memorial Hermann Occupational Health Clinic for titers or immunizations referenced within the Vaccine Preventable Disease Policy at no cost to you. I do hereby attest that the information above is true, accurate, and complete to the best of my knowledge, and I understand that any falsification, omission or concealment of any medical fact may subject me to disciplinary action up to and including termination of employment, or suspension of privileges. Please review the “Memorial Hermann Vaccine Preventable Disease Policy” for additional information.

Sign : __________________________________ Print : __________________________________ Date: _______________

Memorial Hermann Use Only (Copy to) MSO Office: _______________________ OH Office: ________________________

(CIRCLE ONE)

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

To the employer: Answers to questions in Section 1, and to question 9 in section 2 of Part A, do not require medical examination. To the employee: Can you read (check one): Yes No cvcvc

Your employer must allow you to answer this questionnaire during normal working hours, or at a time and place

that is convenient to you. To maintain your confidentiality, your employer or supervisor must not look at or

review your answers, and your employer must tell you how to deliver or send this questionnaire to the health

care professional who will review it.

Part A. Section 1 (Mandatory) The following information must be provided by every employee who has been

selected to use any type of respirator (PLEASE PRINT).

1. Todays date: _______________

2. Your Name: ______________________________________________________

3. Your Age (to the nearest year): _____________

4. Sex (Check One): Male Female

5. Your Height: __________Ft. __________In.

6. Your Weight: __________

7. Your Job Title: ___________________________________________________

8. A phone number where you can be reached by the health care professional who reviews this questionnaire

(include area code): _____________________

9. The best time to phone you at this number: ___________________

10. Has your employer told you how to contact the heath care professional who will review this questionnaire

(Check one) Yes No

11. Check the type of respirator you will use (you can check more than one category):

a. _____ Disposable respirator (i.e., N95 or N100 (HEPA) TB respirator, half face respirator

b. _____ Other type (for example, full – facepiece type, powered-air purifying, supplied-air, self-contained

breathing apparatus (SCBA). Check the approriate type(s).

12. Have you worn a respirator (check one): Yes No If “yes”, what type(s): __________________

Part A. Section 2. (Mandatory) Questions 1 through 9 below must be answered by every employee who has

been selected to use any type of respirator (please check “yes” or “no”).

1. Do you currently smoke tobacco, or have you smoked tobacco in the last month? Yes No

2. Have you ever had any of the following conditions?

a. Seizures (fits): Yes No

b. Diabetes (sugar disease): Yes No

c. Allergic reactions that interfere with your breathing? Yes No

d. Claustrophobia(fear of closed–in places): Yes No

e. Trouble smelling odors: Yes No

3. Have you ever had any of the following pulmonary or lung problems?

a. Absestosis Yes No g. Silicosis Yes No

b. Asthma Yes No h. Pneumothorax (collapsed Lung) Yes No

c. Chronic Bronchitis Yes No i. Lung Cancer Yes No

d. Emphysema Yes No j. Broken Ribs Yes No

e. Pneumonia Yes No k. Any chest injuries or surgeries Yes No

f. Tuberculosis Yes No l. Other lung problems that you’ve

been told about? Yes No

OSHA Respirator Medical Evaluation Questionnaire

4. Do you currently have any of the following symptoms of pulmonary or lung illness?

a. Shortness of breath:

c. Shortness of breath when walking with other people at an ordinary pa

e. Shortness of breath when washing or dressing yourself:

f. Shortness of breath that interferes with your job:

g. Coughing that produces phlegm (thick sputum):

h. Coughing that wakes you early in the morning:

i. Coughing that occurs mostly when you are lying down:

j. Coughing up blood in the last month:

k. Wheezing:

l. Wheezing that interferes with your job:

m. Chest pain when you breathe deeply:

n. Any other symptoms that you think may be related to lung problems:

5. Have you ever had any of the following cardiovascular or heart problems?

a. Heart attack:

b. Swelling in your legs or feet (not caused by walking):

c. Angina:

d. High blood pressure:

e. Stroke:

f. Heart arrhythmia (heart beating irregularly)

g. Heart failure:

h. Any other heart problem that you’ve been told about:

6. Have you ever had any of the following cardiovascular or heart symptoms?

a. Frequent pain or tightness in your chest:

b. Pain or tightness in your chest during physical activity:

c. Pain or tightness in your chest that interferes with your job:

d. In the past two years, have you noticed your heart skipping or missing a beat:

e. Heartburn or indigestion that is not related to eating:

f. Any other symptoms that you think may be related to heart or circulation problems:

7. Do you currently take medication for any of the following problems?

a. Breathing or lung problems

b. Heart trouble: d. Seizures (fits):

8. If you’ve used a respirator, (TB Mask) have you ever had any of the the following problems?

(If you’ve never used a respirator, go to question 9)

a. Eye irritation: d. General weakness or fatigue:

b. Skin allergies or rashes: e. Any other problem that interferes

with your use of a respirator:

9. Would you like to talk to the health care professional who will review this questionnaire

about your answers to this questionnaire?

To the best of my knowledge, the information I have provided is true and accurate.

___________________________________________ _______________________

Employee Signature Date

Occupational Health Use Only

_______ Employee cleared for fit testing _____ Employee clearance pending medical director review.

_______ Employee referred to personal physician

Signature: __________________________________________ Date: _____________________

12/2016 Update

NOTICE OF NO WORKERS’ COMPENSATION INSURANCE COVERAGE

COVERAGE: Memorial Hermann Health System, Memorial Hermann Hospital System, MHMG, MHMD,

Memorial Hermann Health Insurance, Memorial Hermann Employer Solutions, Memorial Hermann Health

Ventures, Inc., MH Physicians of Texas, and Memorial Hermann Community Benefit Corporation have

elected not to obtain workers’ compensation insurance coverage. As an employee of a non-covered employer, you

are not eligible to receive workers’ compensation benefits under the Texas Workers’ Compensation Act. However, a

non-covered employer can and may provide other benefits to injured employees. You should contact your employer

regarding the availability of other benefits or compensation for a work-related injury or illness. In addition, you may

have rights under the common law of Texas should you suffer an on the job injury or illness. Your employer is

required to provide you with coverage information, in writing, when you are hired or whenever the employer

becomes, or ceases to be, covered by workers’ compensation insurance.

SAFETY HOTLINE: The Texas Department of Insurance, Division of Workers’ Compensation has established a

24 hour toll-free telephone number for reporting unsafe conditions in the workplace that may violate occupational

health and safety laws. Employers are prohibited by law from suspending, terminating, or discriminating against any

employee because he or she in good faith reports an alleged occupational health or safety violation. Contact

Workers’ Health & Safety at 1-800-452-9595.

COBERTURA: Memorial Hermann Health System, Memorial Hermann Hospital System, MHMG, MHMD,

Memorial Hermann Health Insurance, Memorial Hermann Employer Solutions, Memorial Hermann Health

Ventures, Inc., MH Physicians of Texas, and Memorial Hermann Community Benefit Corporation ha elegido

no obtener cobertura de compensacion para trabajadores. Como empleado de un usted no es elegible para recibir

beneficios de compensacion bajo la Ley de Compensacion para Trabajadores de Texas. Sin embargo, un empleador

sin cobertura puede y debe proporcionar otros beneficios a los empleados lesionados. Usted debe comunicarse con

su empleador para obtener informacion acerca de la disponibilidad de otros beneficios o compensacion por una

lesion o enfermedad relacionada con el trabajo. Ademas, usted puede tener derechos bajo la ley de “Derecho

Comun” de Texas, si usted ha sufrido una lesion o enfermedad relacionada con su trabajo. Es requerido que su

empleador le proporcione informacion acerca de la cobertura, por escrito, cuando es contrado o cuando su

empleador obtiene o deja de tener cobertura de seguros de compensacion para trabajadores.

LINEA DIRECTA PARA REPORTAR CONDICIONES INSEGURAS: Departmento De Seguros de Texas,

Division De Coompensacion Para Trabajadores ha establecido una linea telefonica gratuita las 24 horas, para

reporter condiciones inseguras en el lugar de trabajo que pudiesen violar las leyes ocupacionales de salud y

seguridad. La ley prohibe que los empleadores suspendan, despidan o discriminen contra un empleado o empleada

porque el o ella, de Buena fe, reporta una presunta violacion ocupacional de salud o seguridad. Comuniquese con la

Seccion de Seguridad y Salud al telefono 1-800-452-9595.

I have read and understand the above notice.

He leido y entiendo esta notificacion.

EMPLOYEE:

EMPLEADO:

EMPLOYER:

PATRON:

DATE:

FECHA: