Submitted by ahs-admin on Tue, 04/13/2021 - 16:57 Date * MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year20222023202420252026 Year Last Name * First Name * Middle Name Maiden Name Email Phone Number * Street Address * Address Line 2 City * State * AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP / Postal Code * Date of Birth * MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year Gender * Male Female Volunteer Position/Area * Medical Conditions Do you have or have you experienced any of the following? If yes, explain in more detail under "current medical problems." Please CHECK ONLY if applicable Balance Problems, Hearing Loss Or Abnormal Hearing Test Eye Pain Or Problems With Vision Dizziness Or Fainting Spells Seizures, Convulsions, Or Epilepsy Diabetes Or Sugar In Urine Skin Rashes Or Other Skin Problems Shortness Of Breath, Asthma, Or Lung Problems Heart Problems, Chest Pain, Or High Blood Pressure Excessive Bleeding Or Hemophilia Stomach Problems, Ulcer, Or Diarrhea Unexplained Weight Loss Spleen Removal Or A Disease Affecting The Immune System Night Sweats, Chronic Cough, Spit Or Cough Up Blood Depression Or Any Neuropsychiatry Condition Requiring Medication Frequent Urinating Or Dark Urine Arthritis, Joint Or Muscle Pain, Difficulty Lifting Fractured Bones Or Dislocations Reaction To Soap Or Other Chemicals Hernia Or Hernia Repair Any Other Problems Which Cause Activity Limitations None of the above Describe Current Medical Problems: Have you ever injured your back? * Yes No Please explain/describe Have you ever had or been treated for tendinitis, carpal tunnel, hand, arm, or shoulder problems? * Yes No Please explain/describe Do you take any medications? * Yes No If yes, please list your medications Do you have any physical or mental conditions that have restricted your ability to work or caused you to miss work? * Yes No If yes, Please explain and list any accommodations that are necessary: Do you have allergies to: (check all that apply) * Drugs/Medications Chemicals/Household Products Insect Bites Foods Pollens/Dust Latex Talc Certain Types Of Clothing/Gloves I have no allergies Describe allergy In previous jobs you worked in areas where you may have been exposed to: (check all that apply) * Radiation Chemotherapy Ethylene Oxide Mercury Asbestos/Beryllium Formaldehyde Anesthetic Gases Sand/Dust Noise Solvent/Chemicals Infectious Disease Smoke Not applicable Describe product manufactured, job performed, length of employment, known exposures, and protective equipment used: Diseases, Vaccinations or Antibodies Section Please check the box(es) that describe the diseases, vaccinations, or antibodies titer you have had. When indicated, include the date of vaccination or titer completion. * Accurate information is very important; all information is confidential. Have you tested positive for HIV? * Yes No Would you like to be tested for HIV? Yes No Have you tested positive for Hepatitis C? * Yes No Would you like to be tested for Hepatitis C? Yes No Do you have record of your MMR Vaccine (Rubeola, Rubella Mumps)? * Yes No If NO - The Employee Health Nurse will drawn a titer (antibody titer is a laboratory test that measures the level of antibodies in a blood sample) at the time of your appointment. If YES, please bring a copy of your vaccination records to your appointment. Have you tested positive for Hepatitis B? * Yes No Would you like to be tested for Hepatitis B? Yes No Have you been immunized or had Chicken Pox Disease? * Yes No Would you like to receive the Chicken Pox Vaccine? Yes No Do you have record of your Tdap Vaccine (Tetanus, Diphtheria, Pertusssis/whooping cough)? * Yes No If YES, please bring a copy of your vaccination records to your appointment. Have you had a Pneumonia Vaccine? * Yes No Date of last Pneumonia Vaccine MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year Have you had an Influenza (Flu) Vaccine this year? * Yes No Date of last Influenza (Flu) Vaccine MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year2022202320242025 Year Have you had or tested positive for Tuberculosis (BCG)? * Yes No Date of last positive test MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year When was your last chest x-ray? MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year Please email us your most recent immunization record. In order to ensure the most secure process for handling your personal information, your Immunization Record should be emailed to Wendy.andersen@portmed.org. Please use a Subject line like: "Volunteer Attachment: {Your Name}". You can start the email by clicking here. If you are pregnant and have any questions or concerns regarding fetal protections, please contact the Employee Health Coordinator. You are also encouraged to discuss the type of work you are doing in the hospital with your health care provider. I understand that a misrepresentation or omission of fact may be cause for the withdrawal of my conditional offer of employment or the termination of my employment regardless of when the misrepresentation or omission is discovered. I further understand information contained in this form is confidential. The information is needed by Employee Health to address health and safety concerns and provide employees with necessary information. Applicant's Signature * Submit