Annual Health Screen - Medside Healthcare

ANNUAL HEALTH SCREEN FORM

Patient Information

First Name(*)

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Last Name(*)

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Middle Name

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Date of Birth(*)

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PLEASE COMPLETE ONLY ONE OF THE FOLLOWING ANSWERS (*)

1. I have had no changes to my emergency contact information since the last Health Screen Questionnaire was completed. If this option is checked, skip to #3.

2. I have had the following changes to my emergency contact information since the last Health Screen Questionnaire was completed:

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3. I have had no changes in my health status since the last Health Screen Questionnaire was completed. If this option is checked, skip to #5.

4. I have had the following changes in my health status since the last Health Screen Questionnaire was completed:

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Emergency Contact Name

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Emergency Contact Relationship

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Emergency Contact Phone Number

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Emergency Contact Alternate Phone Number

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Other:

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Explanations to the above statements (attach additional sheets if necessary):

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TB Questionnaire

(check any symptoms that you have had within the last year):

Other:

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I certify that I have answered these questions honestly to the best of my knowledge.

Employee Signature(*)

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Security(*)

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Date(*)

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Health Screen Form

ANNUAL HEALTH SCREEN FORM

PLEASE COMPLETE ONLY ONE OF THE FOLLOWING ANSWERS (*)

TUBERCULOSIS SCREEN

TB Questionnaire

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