**Occupational Health**

###### VAPHS, University Dr

Pittsburgh, PA 15240

**Appointment date** [     ]{.underline} **Time** [     ]{.underline}

#### INITIAL EXAM FORM

## [VAPHS: Animal Exposure Preventive Medicine Program HEALTH QUESTIONNAIRE]{.underline}

**(Complete and bring to your appointment with Occupational Health).**

VAPHS wants to reassure all individuals who have enrolled or are
scheduled to enroll in this program, that your medical information will
be handled with the strictest confidence and in compliance with the
HEALTH INSURANCE PORTABILITY and ACCOUNTABILITY ACT of 1996 (HIPAA).
Your personal and Medical information will only be available to those
clinical care providers in Employee Health with a need to know.

### Please Print or Type 

Name: [          ]{.underline} Social Security **#:
[     ]{.underline}**

Department: [          ]{.underline} VA Mailing Address:
[     ]{.underline}

Telephone Number [          ]{.underline} Female Male Date of Birth:
[     ]{.underline}/[     ]{.underline}/[     ]{.underline}

Job/Position:[     ]{.underline} Job Duties:[     ]{.underline}

PI/Supervisor Name & Ext: [     ]{.underline} **IACUC Protocol \#**
[     ]{.underline}

**I. *(if applicable)***

### Must be completed by Employee and SUPERVISOR or PRINCIPAL INVESTIGATOR

### 

1.  Species contact within VA Pittsburgh Healthcare System (check all
    that apply):

**Dog** **Cat**

**Nonhuman primate** (Baboon, Monkey, etc.), please specify
[     ]{.underline}

**Sheep, Goats, Pig, Calves,** please specify [     ]{.underline}

**Rodents** (Mice, Rats, Hamster, Gerbil, Guinea Pig, etc.), please
specify [     ]{.underline}

**Rabbit**

**Other**, please list: [          ]{.underline}

2.  Total number hours of animal exposure/contact per week at work:
    [          ]{.underline}

3.  For use with **live animals** only, any work with:

A\) **Recombinant DNA** Yes No

B\) **Infectious Agents** Yes No please list: [     ]{.underline}

C\) **Bloodborne Pathogens** Yes No

D\) **Human Cell lines** Yes No

E\) **Very Hazardous Agents** Yes No please list: [     ]{.underline}

F\) **Radiation** Yes No please list: [     ]{.underline}

G\) **Lasers** (Class 3b, 4a) Yes No please list: [     ]{.underline}

H\) **Toxins** Yes No please list: [     ]{.underline}

***[I) Exposure to anesthetic gases]{.underline}***
***[Yes]{.underline}*** ***[No please list:      ]{.underline}***

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Name and Signature of Supervisor or Principal Investigator** **Date**

II\.

  ------------------------------- ----- ---- ---------------------------------------------------------- ----- ----
  GENERAL OCCUPATIONAL HISTORY    YES   NO   LATEX HISTORY                                              YES   NO

  **A**. Have you ever used                  **A**. Have you ever had an anaphylactic (severe, life           
  protective clothing or                     threatening) reaction to latex devices or products?              
  Equipment?                                                                                                  

  Respirators (if yes, give                  **B**. Have you ever been told by a Doctor that you have         
  type:[     ]{.underline} )                 an allergy to any latex product?, If yes,                        
                                             specify:[     ]{.underline}                                      

  Hearing Protection                         **C**. Were you born with any birth defects or limiting          
                                             conditions which may predispose to latex sensitivity             
                                             (spina bifida, Myeloma, myelodysplasia)                          

  Protective suit/isolation gown             **D**. After handling latex products have you ever               
                                             experienced any of the following:                                

  Barrier Gloves                             Difficulty breathing                                             

  Eye Protection                             Chapping or 'cracking' of hands                                  

  **B**. At work, have you ever              Runny nose/congestion                                            
  been exposed to, or worked with                                                                             
  any of the following types of                                                                               
  chemicals:                                                                                                  

  Chemotherpaeutics                          Itchiness (hands/eyes)                                           

  Bloodborne Pathogens                       Redness                                                          

  Asbestos                                   Swelling                                                         

  Lasers                                     Hives                                                            

  Radiation/Radiology Exposure               Other                                                            

  Mercury/Lead/Cadmium (i.e.                 **E**. Have you had an allergic reaction to any of the           
  heavy metals)                              following:                                                       

  Other                                      Avocados/bananas/chestnuts/kiwis/papaya/peaches/potatoes         
  Materials?[     ]{.underline}                                                                               

                                             Baby bottles/nipples/balloons/erasers                            

  INFECTIOUS DISEASE:                        Elastic waistbands/elastic bandages                              
  Tuberculosis:                                                                                               

  Have you, or anyone in your                Face masks/foam pillows                                          
  family ever had                                                                                             
  Tuberculosis/TB?                                                                                            

  Have you ever had a TB skin                Hot water bottles/ostomy bags/ condoms                           
  test? (Date of most recent: )                                                                               

  Have you ever had a reaction to            Rubber bands/rubber gloves/rubber grips                          
  the TB Skin test?                                                                                           

  IF yes, were you treated with              Other [     ]{.underline}                                        
  INH? Date of last chest                                                                                     
  X-ray:[     ]{.underline} o                                                                                 
  ------------------------------- ----- ---- ---------------------------------------------------------- ----- ----

+----------------------+----+------+------+---+---+----------------+---+---+
| Do you work with, or | Wo | I    | Dat  |   |   | Do you work    | Y | N |
| have you been        | rk | mmun | e(s) |   |   | with or are    | E | O |
| immunized            | Wi | ized | of   |   |   | exposed to     | S |   |
|                      | th |      | Immu |   |   | Anesthetic     |   |   |
| against any of the   |    |      | niza |   |   | gases?         |   |   |
| following:           |    |      | tion |   |   |                |   |   |
+----------------------+----+------+------+---+---+----------------+---+---+
| Botulinum            |    |      |      |   |   | If yes, is     |   |   |
|                      |    |      |      |   |   | there any      |   |   |
|                      |    |      |      |   |   | prior history  |   |   |
|                      |    |      |      |   |   | of any of      |   |   |
|                      |    |      |      |   |   | these medical  |   |   |
|                      |    |      |      |   |   | problems:      |   |   |
+----------------------+----+------+------+---+---+----------------+---+---+
| Vaccinia             |    |      |      |   |   |                |   |   |
+----------------------+----+------+------+---+---+----------------+---+---+
| Q Fever              |    |      |      |   |   | Reproductive   |   |   |
|                      |    |      |      |   |   | problems or    |   |   |
|                      |    |      |      |   |   | disorders for  |   |   |
|                      |    |      |      |   |   | you or your    |   |   |
|                      |    |      |      |   |   | spouse?        |   |   |
+----------------------+----+------+------+---+---+----------------+---+---+
| Rabies virus         |    |      |      |   |   |                |   |   |
+----------------------+----+------+------+---+---+----------------+---+---+
| Measles Virus        |    |      |      |   |   |                |   |   |
+----------------------+----+------+------+---+---+----------------+---+---+
| Human Retroviruses   |    |      |      |   |   |                |   |   |
+----------------------+----+------+------+---+---+----------------+---+---+
| Meningococcus        |    |      |      |   |   | Liver          |   |   |
|                      |    |      |      |   |   | Disorders      |   |   |
+----------------------+----+------+------+---+---+----------------+---+---+
| Tetanus Diphtheria   |    |      |      |   |   | Kidney         |   |   |
| (Td)                 |    |      |      |   |   | Disorders      |   |   |
+----------------------+----+------+------+---+---+----------------+---+---+
| Other:               |    |      |      |   |   | Hemat          |   |   |
| [     ]{.underline}  |    |      |      |   |   | ological/blood |   |   |
|                      |    |      |      |   |   | disorders      |   |   |
+----------------------+----+------+------+---+---+----------------+---+---+

+------------------------------+---+---+-------------------------------+
| Do you have, or have you     | Y | N | COMMENTS (if YES)             |
| ever had:                    | e | o |                               |
|                              | s |   |                               |
+------------------------------+---+---+-------------------------------+
| Allergic                     |   |   |                               |
| rhin                         |   |   |                               |
| itis/conjunctivitis/hayfever |   |   |                               |
+------------------------------+---+---+-------------------------------+
| Anaphylaxis                  |   |   |                               |
+------------------------------+---+---+-------------------------------+
| #  Asthma                    |   |   |                               |
+------------------------------+---+---+-------------------------------+
| Chronic cough                |   |   |                               |
+------------------------------+---+---+-------------------------------+
| Eczema/urticaria/hives       |   |   |                               |
+------------------------------+---+---+-------------------------------+
| Family history of allergic   |   |   |                               |
| disease (explain if          |   |   |                               |
| yes)[     ]{.underline}      |   |   |                               |
+------------------------------+---+---+-------------------------------+
| Prior history of allergic    |   |   |                               |
| symptoms with animal         |   |   |                               |
| exposure                     |   |   |                               |
+------------------------------+---+---+-------------------------------+
| Itching, tearing or swelling |   |   |                               |
| of eyes                      |   |   |                               |
+------------------------------+---+---+-------------------------------+
| Nasal discharge              |   |   |                               |
+------------------------------+---+---+-------------------------------+
| Coughing                     |   |   |                               |
+------------------------------+---+---+-------------------------------+
| Chest tightness or wheezing  |   |   |                               |
+------------------------------+---+---+-------------------------------+
| Skin rash or itching         |   |   |                               |
+------------------------------+---+---+-------------------------------+

*(Employees with suspected work related allergies should seek evaluation
and treatment from their physician.)*

  ------------------------------- ---- -- --------------------------------
  Skin Diseases                           

  Diabetes                                

  Seizure disorder                        

  Back Pain                               

  Color blindness                         

  Other:[     ]{.underline}               
  ------------------------------- ---- -- --------------------------------

**III.**

A.  Have you ever contracted an occupational illness, or had a serious
    injury from an animal or in animal-related work? Yes No If yes,
    please explain in detail. [     ]{.underline}

B.  Have you had a splenectomy? Yes No

> Are you on any immunosuppressant drugs? Yes No

C.  Please note any other current health problems/history you consider
    significant: [     ]{.underline}

D. Are you being treated by a physician for a health problem? Yes No (If
yes, list):[     ]{.underline}

E. Are you currently taking any medications (Over the Counter or
Prescribed)? Yes No (If yes, list):[     ]{.underline}

F. Do you have any allergies to medication? Yes No (If yes,
list):[     ]{.underline}

G.. Do you have any work restrictions or physical limitations? Yes No
(If yes, list):[     ]{.underline}

> H. Do you require any work accommodations for the position for which
> you are applying or presently performing? Yes No (If yes,
> list):[     ]{.underline}

I.  List all hospitalizations and surgeries with Approximate dates:

    a.  [     ]{.underline}

    b.  [     ]{.underline}

    c.  [     ]{.underline}

**I certify I understand all requests for information on this form and
that the information I supplied is correct**.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

EMPLOYEE SIGNATURE and DATE

\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*

**IV. For VAPHS Occupational Health Service Use Only:**

I have reviewed the information provided (Medical Practitioner Signature
&
Date):\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> [DATE]{.underline} (or NA) [DATE]{.underline}

Tuberculin Skin Test
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ NEG POS
\_\_\_\_\_\_\_\_\_\_\_\_\_ mm

Tetanus-diphtheria Vaccine \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
RABIES 1: \_\_\_\_\_\_\_\_\_\_\_\_\_

> RABIES 2: \_\_\_\_\_\_\_\_\_\_\_\_\_
>
> RABIES 3: \_\_\_\_\_\_\_\_\_\_\_\_\_

Bloodborne Pathogen surveillance

HBV vaccine 1: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
POLIO vaccine \_\_\_\_\_\_\_\_\_\_\_\_\_

HBV vaccine 2: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

HBV vaccine 3: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
VZV vaccine \_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
(Varicella)

TOXOPLASMOSIS \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**No** **Yes** Exposure to anesthetic gases.

If Yes, does review of reproductive history reveal any suspicion of
work-related
problems?)\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

If yes, Medical Surveillance will be initiated for exposure to
anesthetic gases (which includes baseline CBC, liver profile, renal
profile, and medical and reproductive history updates; if NIOSH limits
are exceeded in the Animal Research facility, blood workup will be
repeated).

RECOMMENDATIONS/ NOTES/ ***[Comments from Physical exam
results]{.underline}***: