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Are You in Need of Home Health Care Services In Upstate New York?
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Michigan
Missouri
New York
CDPAP
Downstate NY Home Care
Upstate NY Home Care
Now Hiring
Home Care
Forms
Contact
Choose Your State
Michigan
Missouri
New York
CDPAP
Downstate NY Home Care
Upstate NY Home Care
Now Hiring
Home Care
Forms
Contact
607-432-1005
Employee Health Assessment
Name
This field is for validation purposes and should be left unchanged.
Name
(Required)
First
Last
Last 4 of Social Security #
(Required)
Email
(Required)
Phone
(Required)
TB Screening/Risk Assessment
Heart Disease
(Required)
Yes
No
Diabetes
(Required)
Yes
No
Tuberculosis
(Required)
Yes
No
Visual Impairment
(Required)
Yes
No
High Blood Pressure
(Required)
Yes
No
Chickenpox/Varicella
(Required)
Yes
No
Hearing Impairment
(Required)
Yes
No
Epilepsy or Seizure Disorder
(Required)
Yes
No
Visual Impairment (corrected by glasses)
(Required)
Yes
No
Drug/Alcohol Abuse or Addiction
(Required)
Yes
No
Psychiatric or Behavioral Disorder
(Required)
Yes
No
Other
Have you ever been treated for a back injury?
(Required)
Yes
No
If Yes, when
(Required)
Do you have any sensitivity or allergy to latex products?
(Required)
Yes
No
It is the employee’s responsibility to seek treatment of allergies or conditions, and to notify the Coordinator of any allergy/condition, which could potentially interfere or limit job performance. Have you ever received:
Workmen's compensation?
(Required)
Yes
No
If Yes, when
(Required)
Disability?
(Required)
Yes
No
If Yes, when
(Required)
Are you currently under the care of physician?
(Required)
Yes
No
If Yes, please explain
(Required)
List all prescription medications that you are currently taking
(Required)
(Enter N/A if none)
TB Screening/Risk Assessment
1) Do you have a history of temporary or permanent residence (for >1 month) in a county with a high TB rate (i.e. any country other then Australia, Canada, New Zealand, The United States, and those in western or northern Europe)?
(Required)
Yes
No
2) Do you have current or planned immunosuppression, including human immunodeficiency virus infection, receipt of an organ transplant, treatment with ‎ an TNF-alpha antagonist (e.g., infliximab, etanercept, or other), chronic steroids (equivalent of prednisone>15mg/day for>1 month) or other immunosuppressive medication?
(Required)
Yes
No
3) Have you had close contact with someone who has TB disease?
(Required)
Yes
No
4) Have you ever been treated for latent TB infection?
(Required)
Yes
No
5) Do you have any of the following symptoms: Productive cough for more then 3 weeks: Coughing up blood: unexplained weight loss: Fever, chills, or‎ drenching night sweats for no known reason: persistent shortness of breath: unexplained fatigue for more than 3 weeks: Chest pain?
(Required)
Yes
No
6) Have you ever had a prior diagnosis of active TB, latent TB infection, a positive skin test, or positive blood test for TB?
(Required)
Yes
No
7) Have you ever been treated with medication for TB or for a positive TB test?
(Required)
Yes
No
‎
(Required)
I have read the above and declare that I have no injury, illness or ailment other then as specifically identified. I certify that I am not habituated to any depressants, stimulants, narcotics, drugs ,alcohol, or other substances that may alter my behavior
Signed Name
(Required)
Date
(Required)
MM slash DD slash YYYY
Untitled
(Required)
I agree that my signature on this document is as valid as if I signed the document in writing
