medical and occupational history questionnaire - SSM Health Care

MEDICAL AND OCCUPATIONAL HISTORY
QUESTIONNAIRE
Medical and Occupational
History
Have you had any
surgeries/operations:
On you back, arm, leg, or knee
To treat a hernia
Varicose veins
Other operations
Have you ever been hospitalized
Allergy - Have you ever had or do
you currently have:
Serious allergy
Bad reaction to any medications
Advised not to take any medication
Skin - Have you ever had or do
you currently have
Hives/eczema or rash
Chronic skin problems
Excessive skin dryness
Problems with "easy bruising"
Chemical or jewelry rash/sensitivity
Neuro - Have you ever had or do
you currently have:
A psychiatric or emotional problem
Numbness/weakness/paralysis
Dizziness or fainting spells
Severe/frequent or migraine
headaches
Head Injury, concussion, or skull
fracture
Neurological disorders
Seizures or blackouts
Stroke
Please check "yes" or "no". If "yes", give details in
REMARKS section.
Yes No Yes No
Eyes/Ears-Have you ever
had or do you currently
have:
Hearinq Loss
Frequent ear infections
Ringing in ears
Other ear problems
Glaucoma or cataracts
Red eyes
Eye Injury/vision loss
Other eye problems
Glasses/contacts
Date of last visual screen
Head/Neck -Have you ever
had or do you currently
have:
Date of last dental exam
Problems with teeth/dentures
Frequent mouth
ulcers/infections
Sinus or hay fever
Frequent sore throats
Frequent nose bleeds
Trouble with thyroid
Problems requiring radiation
to the neck area
Lungs - Have you ever had
or do you currently have:
Asthma or wheezing
Coughed up any blood
Shortness of breath without
apparent reason
TB or positive skin test for TB
3-4-06 Questionnairefirefighter.doc Page 1
THROUGH OUR EXCEPTIONAL HEALTH CARE SERVICES, WE REVEAL THE HEALING PRESENCE OF GOD.

Medical and Occupational
History (continued)
Lungs (continued) - Have you ever
had or do you currently have:
Pneumonia or pleurisy
Do you cough every day, especially
in the morning
Pain or tightness in chest
More than three episodes of
bronchitis in one year
Ever smoked tobacco in any form
Had a chest x-ray
Heart - Have you ever had or do
you currently have:
Rheumatic fever or heart murmur
Heart disease
Treated for heart condition
Unusually cold or bluish-colored
hands or feet
High blood pressure How is it
treated
Do you have a history of elevated
cholesterol
Anemia or any blood disease
Phlebitis, varicose veins, or blood
clots/poor circulation
Pain with activity
Please check "yes" or "no". If "yes", give details in
REMARKS section.
Yes No Yes No
Yellow jaundice or hepatitis
Problems withy your
pancreas
Gallbladder disease
Kidneys - Have you ever
had or do you currently
have:
Bladder or kidney infections
Kidney stones
Burning or discomfort on
urination
Hernia
Blood in urine
Miscellaneous - Have you
ever had or do you currently
have:
Diabetes or sugar in your
blood
Cancer of any kind
Muscle-Skeletal: Have you
ever had or do you currently
have:
Arthritis, rheumatism, neck,
back, or spine injury or
disease
Been treated for a back
problem
Recurrent stiffness or back
pain
Bursitis, tendonitis
GI - Have you ever had or do you
Recurrent pulled muscles or
currently have:
sprains
Ulcers
Hand/wrist iniury or problem
Hiatal hernia
Kip or knee iniury or problem
Indigestion, pain, or unusual burning
Ankle or foot injury or
in stomach
problem
Vomiting of blood
Frostbite
Job requiring heavy lifting or
Bloody/tarry bowel movements
standing, or sitting for long
periods of time
Colitis or nervous stomach Any broken bones
3-4-06 Questionnairefirefighter.doc Page 2
THROUGH OUR EXCEPTIONAL HEALTH CARE SERVICES, WE REVEAL THE HEALING PRESENCE OF GOD.

Medical and Occupational
History (continued)
Please check "yes" or "no", if "yes", give details in
REMARKS section.
Yes No Yes No
For Females Only: Have you
ever had or do you currently
Work History: Have you
have:
ever:
Been restricted in your work or
Menstrual irregularities
given "light duty" because of
your health or injury
Recurrent problems of the
Left a job because of health
female organs
problems
Been injured on the job and
Breast masses or lumps
treated by a doctor
Do you practice monthly breast
Received compensation for an
self-exam
industrial injury or illness
Are you receiving any
healthcare treatment (e.g.
Date of last pap smear
physical therapy, chiropractic,
acupuncture, medical, etc.)
For Males Only: Have you
Other:
ever had or do you currently Been hospitalized in the last 5
have:
years
Have you had any illness or
Prostate or testicular problems
injury that we have not asked
you about
Breast tenderness, swelling, or
lumps
Do you practice monthly
testicular self-exam
General Lifestyle
Do you exercise three times per
week 30 - 40 minutes each
time Identify types of exercise.
Are you more than 30% above
your ideal weight
Have you received a tetanus
booster in the last 10 years
Have you been immunized
against hepatitis B Date
Do you take any prescription
medications Please list.
Are you currently taking any
over-the-counter medications on
a regular basis Please list.
3-4-06 Questionnairefirefighter.doc Page 3
THROUGH OUR EXCEPTIONAL HEALTH CARE SERVICES, WE REVEAL THE HEALING PRESENCE OF GOD.

Remarks: (Please list details from the Medical and Occupational History Questionnaire)
I certify that the above information is true and complete to the best of my
knowledge. I hereby give ________________ Fire District permission to release this
health-related information to SSM WorkHEALTH.
Signature:
Date:
_________________________________________
_________________________________________
3-4-06 Questionnairefirefighter.doc Page 4
THROUGH OUR EXCEPTIONAL HEALTH CARE SERVICES, WE REVEAL THE HEALING PRESENCE OF GOD.