49 North Airmont Road. Montebello, NY 10901, Phone: (845) 425-6555 Fax: (845) 425-9035


(To be completed by employee)

Employee Name:   Date of Birth:
Today's Date:

Please CHECK the correct response. Since your last physical or health scresening have you:

 Yes    No Have you had any significant illnesses or hospitalizations?
 Yes     No Had Surgery in the past year?
 Yes  No    Had any injuries?
 Yes  No     Started any new medications?
 Yes  No     Had any changes in pre-existing health problems?
Yes No  Developed any new health problems?
 Yes    No      Seen a physician for anything besides a routine physical or minor illness?
 Yes  No      Are you currently taking any prescription medications or over the counter medications?
 Yes  No      Any compliants of shortness of breath, cough or chest pain?
 Yes   No      Do you have any complaints of fever or night sweats?
 Yes    No    Do you know of , or believe there is any health reason why you cannot or should not provide direct patient care?
 Yes   No    Have any unresolved illnesses or medical conditions?
 Yes   No  Do you have a problem with habituation or addiction to alcohol, depressants, stimulants, narcotics or other substances that may alter your behavior?

Give details below for any  "YES" answers:


For personnel who have a known positive PPD and previously negative chest x-ray, Complete this questionnaire with either a yes or no

 Have you noticed any of the following:

  1. Unexplained fevers:  yes  no

6. Hoarseness?  yes  no

  1. Night sweats?  yes  no

7. Bloody Sputum?  yes  no

  1. Unintentional Weight Loss?  yes  no

8. Chest Pain?  yes  no

  1. Cough for 3 or more weeks?  yes  no

9. Fatigue?  yes  no

  1. Loss of appetite?  yes  no

10. Have you completed INH Therapy?  yes  no


I understand that this screening tool/questionnaire is not to be intended to replace a complete physical examination, nor medical care by my physician. The answers I have provided are accurate to the best of my knowledge.

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