Employee Health Record

A completed, signed Employee Health Record is required by Professional Nursing Service for health care employees. You must complete and sign sections 1-4. Your primary care provider must complete section 5.

You cannot begin work for PNS until we have received this Employee Health Record completed and signed.

Items in red are REQUIRED fields.

1. Personal Information:
First Name:        Middle Initial:
Last Name:       
Current Address:
State:        ZIP:
Date of Birth:
Social Security #:

2. Health: Please indicate by checking the items below if you have or have had any of the following:
Y    N   Head Injury Y    N   Breast Disease/Pain/Lumps
Y    N   Headaches Y    N   Chest Pain/Palpitations
Y    N   Epilepsy/Seizures Y    N   Heart Disease/Rhythm Abnormalities
Y    N   Speech Changes/Impairment Y    N   Cramps/Edema/Pains in Legs
Y    N   Addiction Drug/Alcohol Y    N   Blood Pressure Problems
Y    N   Behavioral Counseling/Disorders Y    N   Changes in Bowel/Bladder
Y    N   Skin Disease/Allergies Y    N   Abdominal Pain/Ulcers
Y    N   Rashes/Lesions/Lumps Y    N   Communicable Disease/TB
Y    N   Environmental/Occupational Exposure Y    N   Sexually Transmitted Disease
Y    N   Visual Impairment/Disturbances Y    N   Joint Disease/Change in ROM
Y    N   Ear Pain/Discomfort/Discharge Y    N   Spinal Disease/Back Pain
Y    N   Nasal Stiffness/Drainage Y    N   Muscle/Coordination Abnormalities
Y    N   Epistaxis Y    N   Parasthesia/Paralysis
Y    N   Upper Respiratory Infections Y    N   Dizziness/Lightheadedness/Syncope
Y    N   Cough(chronic)/Hemoptysis Y    N   Foot Disease/Problems
Y    N   Dental/Gum Disease Y    N   Kidney/Renal Disease
Y    N   Lip/Oral Lesions Y    N   Bowel Disease/Hernia
Y    N   Sore Throat/Tongue Y    N   Varicosities
Y    N   Difficulty Chewing/Swallowing Y    N   Menstrual Irregularities
Y    N   Thyroid/Endocrine Disease Y    N   Cyanosis/Shortness of Breath
Y    N   Weight Change Y    N   Genitourinary Irregularities

If you checked any of the above, please explain:

3. Medical History (Past ten years):
A. Are you under the care of a physician/primary care provider?   Yes    No
If YES, reason(s):
B. Are you taking medications?   Yes    No
If YES, type:
C. Have you had any operations or hospitalizations for illness?   Yes    No
If YES, explain and give dates:
D. Have you had any accidents requiring medical attention?   Yes    No
If YES, explain and give dates:
E. Are you willing to have blood/urine screening for drug/alcohol as a condition of employment?   Yes    No
If NO, explain:

4. Tests: Please complete the following and attach copies of results:
A. Chest x-ray (Pos PPD only): Date:       Results:
B. Rubella Titre: Date:       Results:
C. Rubeola Titre: Date:       Results:
D. Varicella Titre: Date:       Results:
E. * PPD (Tuberculin): Date:       Results:
F. Tetanus Booster: Date:       Results:
G. Hepatitis B Vac. 1: Date:       Results:
H. Hepatitis B Vac. 2: Date:       Results:
I. Hepatitis B Vac. 3: Date:       Results:

* Test (if positive, referral for chest x-ray required)

I understand that I must have an annual health screening and annual PPD to retain active employment with Professional Nursing Service. I hereby give my permission to release the results of any test and/or information regarding my health status to Professional Nursing Service.
  Yes      Date:

5. To Be Completed By Health Examiner

Blood Pressure:

Exam results and comments on employee Medical History (see sections 1 and 3):

RN - Please check the box below as your signature validating the information above.
  RN Signature: Yes      Date:

I certify that the above person, to the best of my knowledge, is in good physical and mental health, free from symptoms indicating the presence of an infectious disease and any condition which would interfere with the performance of his/her duties which may require: assistance with transfers; supporting patient during ambulation; providing personal care; and skilled nursing function.
  Primary Care Provider Signature: Yes      Date: