Volunteer - health and medical form – Portneuf Health Partners

Date*

Name*

Last First Middle Maiden

Email

Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth*

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

Describe Current Medical Problems:

Have you ever injured your back?*

No
Yes

Please explain/describe

Have you ever had or been treated for tendinitis, carpal tunnel, hand, arm, or shoulder problems?*

No
Yes

Please explain/describe

Do you take any medications?*

No
Yes

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?*

No
Yes

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)*

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

Have you had an Influenza (Flu) Vaccine this year?*

Yes
No

Date of last Influenza (Flu) Vaccine

Have you had or tested positive for Tuberculosis (BCG)?*

Yes
No

Date of last positive test

When was your last chest x-ray?

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*

By typing my name below, I verify the information I provided on the Pre-Placement Medical and Health History is accurate.

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Volunteer – health and medical form

Volunteer Medical and Health History

Diseases, Vaccinations or Antibodies Section