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ACS Annual Health Assessment/TB Screening Form

ACS HOME CARE LLC – ANNUAL HEALTH ASSESSMENT / TB SCREEN

Employee's name *

First

Last

Date of birth *

Have you experienced any of the following medical problems WITHIN THE PAST YEAR?

Disabling Injury *

No
Yes

Hypertension *

No
Yes

Hernia *

No
Yes

Fainting *

No
Yes

Heart Condition *

No
Yes

Weight Change *

No
Yes

Asthma *

No
Yes

Arthritis *

No
Yes

Mental Illness *

No
Yes

Infections *

No
Yes

Allergies *

No
Yes

Diabetes *

No
Yes

Sinus Problems *

No
Yes

Skin Disease/Rash *

No
Yes

Seizures *

No
Yes

Anemia *

No
Yes

Back Problems *

No
Yes

Stomach Problems *

No
Yes

Surgery *

No
Yes

Fracture *

No
Yes

Have you consulted your physician for this/these problem(s)? *

No
Yes
Not applicable

If Yes, please tell us the problem and the outcome to the problem below:

Problem 1:

Outcome of Problem 1:

Problem 2:

Outcome of Problem 2:

Problem 3:

Outcome of Problem 3:

Problem 4:

Outcome of Problem 4:

Please list all medications you are currently taking (If none, enter "none"): *

Do you have any allergies? *

No
Yes

If Yes, please list all your allergies below:

Do you currently have any of the following symptoms?

Night Sweats *

No
Yes

Chronic/Persistent Cough *

No
Yes

Weight Loss *

No
Yes

Fatigue *

No
Yes

Flu-like Symptoms *

No
Yes

Low grade fever *

No
Yes

Chills *

No
Yes

Lack of Appetite *

No
Yes

Blood color sputum *

No
Yes

Weakness *

No
Yes

Diabetes *

No
Yes

Chest Pain *

No
Yes

Have you been exposed to anyone exhibiting the above signs and symptoms, or someone who has had active tuberculosis within the past year? *

No
Yes

This is to certify, that to the best of my knowledge, there are no health impairments present that are of potential risk to me, patients, or other employees, including the habituation or addiction to depressants, stimulants, narcotics, alcohol or other drugs or substances, which may impair my performance. I understand that any falsification or misrepresentation of my past medical history is grounds for termination of my employment. I also understand that this Health Assessment and TB Screen does not replace medical care and/or advice that I should seek from a physician. *

Clear Signature

Employee's Signature

Date *

Thank you for completing this form. PLEASE SCROLL DOWN THIS PAGE AND CLICK "SUBMIT"

The information directly below, between the lines, is FOR OFFICE USE ONLY. Please scroll down PAST the FOR OFFICE USE ONLY section and "SUBMIT" this form.

______________________________

-= FOR OFFICE USE ONLY =-

Examiner, based on the review of the information provided by this employee, and this screening assessment:

Does this employee appear to be free of any symptoms of infectious disease?

NO | YES

Does this employee appear to be free of potential risk to themselves, patients, or other employees?

NO | YES

Is the employee free of any functional limitation?

NO | YES

Does this employee appear to be able to continue to safely work?

NO | YES

If No was answered to any of the above questions, explain why and the recommended actions for the employee to take:

Examiners Printed Name and Title:

Examiners Signature:

Date of verbal review with the above employee:

______________________________

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