King's Daughters Health System

Please fill out the information below and press Submit.

Can you read?

Personal Information

Full Name

DOB

Last 4 SSN

Todays Date

Occupational History - in the grids below, list jobs in starting with the most recent

New Job

Current Job

Previous Job

Do you require any specific work accomodations?

If yes, explain

Do you have history of any work related injuries?

If yes, explain

Have you ever used a respirator?

If yes, did you experience any difficulty? Explain

Medical History

Are you allergic to any medication?

If yes, explain

Do you have any food or seasonal allergies?

If yes, explain

General or arthroscopic surgeries?

If yes, explain

Hospitalizations for childbirth, illness, injury?

If yes, explain

List all current prescription and over the counter medications

Immunization	Date
TB (within 6 months)
Flu Vaccination
Tdap
Hep A Vaccination
Covid Vaccine

Do you drink alcoholic beverages?

If yes, how much

Do you use tobacco products?

If yes, how much

Are you suffering from any illness today?

If yes, explain

How would you rate your overall health?

If not excellent or good, explain

Review of systems: Have you ever had any of the following?

Problems with ears, eyes, nose, or throat

Glaucoma, cataracts, blindness, color blindness, retinal detachment, other

Ruptured ear drum, ringing of noise in ears, loss of hearing, other

Hoarseness, chronic sore throat, difficulty swallowing, thyroid problems, other

Problems with heart, circulation, or lungs

Wheezing, chronic cough, shortness of breath, asthma, frequent colds, cough up blood, TB, other

Chest pain or pressure, angina, heart attack, heart disease, heart murmur, heart failure, enlarged heart, high blood pressure, heart palpitations or skips, rheumatic fever, swelling of ankles, pain in legs with walking, other

Nervous system disorder

Migraines, neuritis, convulsions, or seizures, fainting, head injuries, epilepsy strokes, TIA, carpal tunnel syndrome, other

Endocrinology Issues

Diabetes, high or low blood sugar, take insulin or medication for sugar

Thyroid issues, adrenal issues

Gastrointestinal disorder

Frequent heartburn, indigestion, reflux, loss of appetite, nausea, vomiting, ulcers, vomited blood, chronic abdominal pains

Recurrent or chronic diarrhea, chronic constipation, blood in bowel movement, black bowel movements, colitis, diverticulitis, jaundice, hepatitis, gall stones, pancreatitis, tumors of stomach, liver, pancreas, colon or intestines

Muscle, joint, or bone problems

Arthritis, gout, loss of fingers/toes

Chronic pain with neck, shoulder, arm, wrist, hand

Chronic pain knees, ankles, feet

Back pain, back issues

Kidney, bladder, or reproductive organ(s) problems

Blood in urine, kidney or bladder infections, kidney stones, tumors of kidney, bladder, ovaries, testes, prostate or uterus

Hematological problems

Anemia, bruising, bleeding problems

Leukemia, lymphoma, cancer, Hodgkin's

Low white cells, immunity problems

Psychiatric or psychological problems

Depression, anxiety/panic attacks, drug use, alcoholism

Claustrophobia (fear of tight spaces)

Following questions must be answered by every employee who has been selected to use any type of respirator. Be prepared to explain all YES answers in comments section.

Have you had any of the following issues?

Chronic bronchitis

If yes, explain

Emphysema

If yes, explain

Pneumonia

If yes, explain

Tuberculosis

If yes, explain

Silicosis

If yes, explain

Asbestosis

If yes, explain

Allergic reactions that interfere with your breathing

If yes, explain

Trouble smelling odors

If yes, explain

Pneumothorax

If yes, explain

Broken ribs

If yes, explain

Any chest injuries or surgeries

If yes, explain

Any other lung problems that you have been told about

If yes, explain

Shortness of breath when walking fast on level ground or walking up a slight hill or incline

If yes, explain

Shortness of breath when walking with other people at an ordinary pace on level ground

If yes, explain

Shortness of breath when washing or dressing yourself

If yes, explain

Shortness of breath that interferes with your job

If yes, explain

Coughing that produces phlegm

If yes, explain

Coughing that wakes you early in the morning

If yes, explain

Coughing that occurs mostly when you are lying down

If yes, explain

Wheezing that interferes with your job

If yes, explain

Chest pain when you breathe deeply

If yes, explain

Any other symptoms that you think may be related to lung problems

If yes, explain

Heart arrythmia

If yes, explain

Pain or tightness in your chest during physical activity

If yes, explain

Pain or tightness in your chest that interferes with your job

If yes, explain

Any other symptoms that you think may be related to your heart or circulation problems

If yes, explain

Have you had any of the following problems with a respirator?

Eye irritation

If yes, explain

Skin allergies or rash

If yes, explain

Anxiety

If yes, explain

General weakness or fatigue

If yes, explain

Any other problem that interferes with your use of a respirator

If yes, explain

Would you like to talk to the health care professional who will review this questionnaire about your answers?

E-Signature (Check box to E-Sign)

OHEM History for New Employees

Please fill out the information below and press Submit.

Personal Information

Occupational History - in the grids below, list jobs in starting with the most recent

New Job

Current Job

Previous Job

Previous Job

Medical History

Review of systems: Have you ever had any of the following?

Problems with ears, eyes, nose, or throat

Problems with heart, circulation, or lungs

Nervous system disorder

Endocrinology Issues

Gastrointestinal disorder

Muscle, joint, or bone problems

Kidney, bladder, or reproductive organ(s) problems

Hematological problems

Psychiatric or psychological problems

Following questions must be answered by every employee who has been selected to use any type of respirator. Be prepared to explain all YES answers in comments section.

Have you had any of the following issues?

Have you had any of the following problems with a respirator?