Occupational medical history questionnaire

Personal history
Medical record number
Name
Age
Sex
Address
Telephone Number
Emergency Contact
Date of birth
Place of birth
Nationality
Native language
Educational Level
Marital status
Department Information
Department ……………………principal supervisor /investigator………………………………………

Social Habits
Do you use tobacco products? yes no If yes mention the type :
Family History
Check if there is any history in your family of
Diabetes Easy Bleeding obesity
Allergy
Hypertension Alcoholism Asthma
Cancer
Heart troubles T.B Psychiatric
illness
Other……………
EXPLAIN:…………………………………………………………………………………………………………
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………….……………
……..
Statement of present health
Are you currently being treated or monitored for any medical conditions? Please list:
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………
……..
Are you currently taking any medications ? please list :
………………………………………………………………………………………………………………………
….
………………………………………………………………………………………………………………………
…
 Have you ever had any surgeries
(medical or ocular ,including Lasik)?
Please list and provide the date of the surgery:

Have you ever had any eye injuries or

diseases including crossed eyes , dry eyes
,macular degeneration ,glaucoma ,retinal
disease cataracts ,eye infections ETC.?
Are you taking any ocular medications or over
the counter eye remedies including artificial
tears ? please list.
Do you wear glasses?

Review of systems
Do you currently or have you ever been treated for any of the following :

CARDIOVASCULAR YES NO UNKNOWN

High blood pressure
High cholesterol
Heart Attack
Stroke
ENDOCRINE
Type I Diabetes
Type II Diabetes
Diabetic Suspect
Thyroid Disorder
Cohn's Disease
ALLERGIC
Allergy to medication
Which ?
Contact Allergy
Which kind of material?
Constitutional
Fever , Weight loss / Gain
Dizziness / fainting .
Gastrointestinal
Colon Cancer
Liver Cancer
Gall Stones
Hepatitis
 YES NO UNKNOWN
Inflammatory Bowel
GENITOURINARY
Kidney stones
Prostate cancer
EARS, NOSE,MOUTH, THROAT
Hearing Loss
Chronic cough
HEMATOLOGIC/LYMPHATIC
Anemia
Breast cancer
Leukemia
Lymphatic cancer
IMMUNOLOGIC
Chicken pox
Herpes zoster virus
AIDS/HIV positive
INTEGUMENTARY (SKIN)
Skin cancer
Lupus
Psoriasis
MUSCULOSKELETAL
Rheumatoid Arthritis
Arthritis
Osteoporosis
Neurological
Bell's palsy
Brain tumor
Parkinson's Disease
Chronic headache
Migraine
Psychiatric
Attention Deficit Disorder
Anxiety
Depression
Dementia
RESPIRATORY
Asthma
Chronic Bronchitis
Emphysema
 YES NO UNKNOWN
COPD
Lung cancer
Tuberculosis
List any additional conditions, not listed above, that you currently have or have ever been treated for .

_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

PAST MEDICAL HISTORY

Check conditions that doctors have followed you for the past :
 High blood pressure\hypertension  High Cholesterol  Liver Disease 
Diabetes("sugar")
 Thyroid problems  kidney Disease  Heart Attack\By-pass Surgery
 Thyroid problems  kidney Disease  Heart Attack\By-pass Surgery
 Heart Failure  Heart Murmur  Mitral Valve Prolapse 
Stroke
 Seizures\Epilepsy  Stomach Problems  Intestinal Problems 
Reflux Disease
 Glaucoma  Psychiatric Illness  Arthritis 
Abnormal PAP
 Cancer Type & Location
 Other
Have you ever had Positive Tuberculosis Test? YES  NO
Rheumatic Fever? YES  NO
Blood Transfusion? YES  NO
List any hospitalizations or surgeries you have had (including C-section):
List any drug allergies :
Are you allergic to latex? YES  NO
List all current medications (including vitamins, herbal and health food preparations)
PREVENTATIVE CARE
When was your last
Tetanus Booster (Td) or Tetanus Toxoid (TT) ___\__\_____
PPD(Tuberculosis Skin Test): ___\__\_____Result?___________
Have you ever had the BGG vaccination (to prevent Tuberculosis)? This is not given in the United states
 NO YES

Measles\Mumps\Rubella(MMR): ___\__\_____ {OR, Did you have these as childhood

Diseases?________ .
 General health care and emergency response YES NO
questions
1-Provide health care to individuals involving exposure to blood or other
potentially infectious materials (OPIM)
2-Handle sharp instrument used by individuals whose work
involves human blood , OPIM, tissues or organs ?
3-Handle human blood or OPIM ?
4-Handle unfixed human tissue ?
5-Perform CPR and /or act as designated first aid responder?
Questions for laboratory personnel does the worker :

6-Handle human blood products such as serum ,plasma and /or cells ?
7-Handle purchased human blood products such as hemoglobin?
8-Handle primary human cell lines ?
9-Handle HIV and /or HBV infected cells / tissues cultures and /or virus
preparations?
10-Handle animals infected with HIV and /or HBV ,or work in areas
where such animals are housed ?
11-Have all bio hazardous materilas that were used in the facility have
been properly disposed , stored or transferred to authorized user ?
12-Have all personal protective equipments such as gowns ,uniforms or
laboratory coats that were worn while in the facility have been properly
disposed of/or disinfected prior to removing from the facility ?
13-Have all needles , syringes or razor blades used in the facility been
properly disposed of in yellow sharps box?
14-Have all work surfaces in the facility been thoroughly decontaminated
using an appropriate disinfectant?(#01 bleach is generally used except
In places where other disinfectants have been recognized as more
effective )
15-Have all wastes from the facility (including tissues , media and other
refuse )have been autoclaved and properly disposed ?
16-Has the biological safety cabinet been properly disinfected ?
Task and procedures:
17-List tasks and procedures that exposed the employee to blood born
pathogens.
 HEPATITIS B VACCINE RECORD

Hepatitis B Vaccine Record (check only one ):

□ I Have previously received the complete hepatitis B Vaccine series on /or about these dates .

Month _______________ Day________________ Year _______________________ .

□ I received the hepatitis B Vaccine series some years ago ,now I request a titer and a Possible booster
if recommended By health care worker .

□ I request the Hepatitis B Vaccine , I have been given the information on it and have had an
opportunity to ask questions . I understand the risks and benefits of Hepatitis B Vaccine and that it is
offered to me at no cost. I understand that complete Protection. Enquires three injections to be
scheduled at 0 ,#month and 6 months.

" I understand that due to my occupational exposure to blood and other potentially infectious
materials , I may be at risk of Acquiring the Hepatitis B Vaccine , I have been given the
opportunity to be vaccinated with Hepatitis B Vaccine at no charge To myself , However , I decline
Hepatitis B Vaccination at this time . I understand that by declining this vaccine , I continue To be
at risk of acquiring Hepatitis B , a serious disease if in the future I continue to have occupational
exposure to blood or other potentially infectious materials and I want to be vaccinated with hepatitis b vaccine
, I can receive the vaccination.

series at no charge to me " .

Employee Name : ___________________________________________________ .

Employee Signature : ________________________________________________ .

Date : _____________________________________________________________ .

Principal Investigator /supervisor Name : _________________________________ .

Principal Investigator /supervisor signature : _______________________________ .

Date : ______________________________________________________________ .
 ‫استمارة تقييم حالة تحصين الموظف‬

‫‪Employee Immunization status‬‬

‫اسم الموظف‪ ...................................................................:‬الوظيفة‪.........................................:‬‬

‫الرقم الوظيفي‪........................................................:‬التاريخ‪......................................................:‬‬
‫‪previous History‬‬ ‫التاريخ السابق‬
‫‪Immunization if‬‬ ‫هل سبق التطعيم‬ ‫اإلصابة‬ ‫المرض‬
‫‪non vaccinated‬‬ ‫‪Previous Immunization‬‬ ‫‪previous History‬‬ ‫‪Disease‬‬

‫ال‬ ‫نعم‬ ‫ال‬ ‫نعم‬

‫‪No‬‬ ‫‪Yes‬‬ ‫‪No‬‬ ‫‪Yes‬‬
‫اإللتهاب الكبدي ب‬
‫‪Hepatitis B‬‬
‫الجدري المائي‬
‫‪Varricella‬‬
‫الحصبة‬
‫‪Measles‬‬

‫النكاف‬
‫‪Mumps‬‬
‫الحصبة األلمانية‬
‫‪Rubella‬‬

‫موعد فحص مستوى‬ ‫التوصيات‬

‫األجسام المضادة‬ ‫‪Recommendation‬‬ ‫مستوى األجسام المضادة‬ ‫المرض‬
‫‪Next Check‬‬ ‫ال يحتاج‬ ‫اعطاء اللقاح‬ ‫‪Antibody titer‬‬
‫‪No Need‬‬ ‫‪Give‬‬
‫االلتهاب الكبدي ب‬
‫‪Hepatitis B antibody‬‬
‫‪titer‬‬

‫الحصبة األلمانية‬
‫‪Rubella antibody‬‬
‫‪titer‬‬

‫اعتماد المدير الطبي‬ ‫الطبيب‪:‬‬ ‫مدير المختبر‪:‬‬

‫االسم‪..................................:‬‬ ‫االسم‪..............................:‬‬ ‫االسم‪...........................:‬‬
‫التوقيع‪..................................:‬‬ ‫التوقيع‪.............................:‬‬ ‫التوقيع‪...........................:‬‬
‫الختم‪:‬‬ ‫الختم‪:‬‬ ‫الختم‪:‬‬
 ‫‪. .......................................... :‬‬ ‫الوظيفة‬ ‫اسم الموظف ‪...................................................................... :‬‬
‫‪.............................................................. :‬‬ ‫التاريخ‬ ‫الرقم الوظيفي ‪......................................................... :‬‬

‫التاريخ‬ ‫حالة التطعيم‬ ‫نوع اللقاح‬

‫‪Date‬‬ ‫‪Employee immunization status‬‬ ‫‪Vaccination type‬‬

‫مكتمل‬ ‫غير مكتمل‬ ‫عدد‬ ‫لم يؤخذ‬ ‫أخذ‬

‫‪complete‬‬ ‫‪N/compl‬‬ ‫المرات‬ ‫‪N/Taken‬‬ ‫‪Taken‬‬
‫‪d‬‬ ‫‪eted‬‬ ‫‪Times‬‬

‫اإللتهاب الكبدي ب‬
‫‪Hepatitis B‬‬
‫اإللتهاب الكبدي أ‬
‫‪Hepatitis A‬‬
‫الجدري المائي‬
‫‪Chicken pox‬‬
‫الحصبة‬
‫‪Measles‬‬
‫الحصبة األلمانية‬
‫‪Rubella‬‬
‫تطعيم الدرن‬
‫‪BCG‬‬
‫اإلنفلونزا‬
‫‪Influenza‬‬
‫الدفتيريا و الجرعة المنشطة‬
‫للكزاز‬
‫‪Diphtheria Tetanus‬‬
‫‪Booster‬‬

‫اعتماد المدير الطبي‪:‬‬ ‫مسؤول التطعيمات ‪:‬‬

‫االسم‪:‬‬ ‫االسم‪:‬‬

‫التوقيع‪:‬‬ ‫التوقيع‪:‬‬

‫التاريخ‪:‬‬ ‫التاريخ‪:‬‬
 ‫تطعيمات الموظف ‪Employee Immunization‬‬
‫التاريخ‬ ‫الرقم الوظيفي‬ ‫الوظيفة‬ ‫إسم الموظف‬

‫إلتهاب الكبد الفيروسي الوبائي (‪)Hepatitis B‬‬

‫الموظف المسؤول‬ ‫تاريخ التطعيم‬ ‫الجرعة‬

‫الجرعة األولى‬
‫الجرعة الثانية‬
‫الجرعة الثالثة‬
‫‪MMR‬‬
‫الحصبة (‪ )Measles‬النكاف (‪ )Mumps‬الحصبة األلمانية (‪)Rubella‬‬

‫الموظف المسؤول‬ ‫تاريخ التطعيم بلقاح ‪MMR‬‬

‫‪Chicken pox‬‬ ‫الجدري المائي‬

‫الموظف المسؤول‬ ‫تاريخ التطعيم بلقاح ‪varicella‬‬

‫إعتماد مدير المركز‪:‬‬ ‫الطبيب‪:‬‬ ‫مسؤول التطعيمات‪:‬‬

‫االسم‪:‬‬ ‫االسم‪:‬‬ ‫االسم‪:‬‬

‫التوقيع‪:‬‬ ‫التوقيع‪:‬‬ ‫التوقيع‪:‬‬

‫التاريخ‪:‬‬ ‫التاريخ‪:‬‬ ‫التاريخ‪:‬‬

 Chicken pox Vaccination _____ / ____/_______ . (OR, Did you have this as a childhood disease ?

______________________________________________ .

Hepatitis A Vaccinations :

(#1) : ____ / _____ / ________ .

(#2) : ___ / _____ / _________ .

Hepatitis B Vaccinations :

(#1) : ___ / _____ / __________ .

(#2) : ___ / _____ / ___________ .

(#3) : ___ / _____ / ___________ .

Occupational History
1. If you are presently employed , what is your Job ?

2- which of the following best describes your current job status ? (please choose only
one)

A. Employed full time ………………………………….. if so , since what year?

B. Employed part time …………………………………. If so , since what year?

3- Note which of the following types of equipment you use :

o Mask respirator.
o Air supply respirator.
o Gloves.
o Coveralls or aprons.
o Safety glasses .
o Other (identify).
 ‫‪Employee screening results‬‬

‫‪HBsAg‬‬ ‫‪HIV Ab‬‬ ‫‪HCV Ab‬‬ ‫‪PPD‬‬

‫‪reading‬‬
‫‪Results‬‬

‫اعتماد مدير المركز‪:‬‬ ‫مدير المختبر‪:‬‬

‫االسم ‪:‬‬ ‫االسم ‪:‬‬
‫التوقيع‪:‬‬ ‫التوقيع‪:‬‬
‫التاريخ‪:‬‬ ‫التاريخ‪:‬‬