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  • Staff Health Form: Demographic Profile

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    Aaron Jay Mondaya
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    This document is a staff health form that collects demographic information, medical history, immunization history, and results of a physical assessment. It gathers the staff member's name, age, gender, date of birth, address, phone number, email, education level, work history, history of medical conditions and allergies, record of immunizations received, results of tuberculosis tests, physical measurements, and notes on the physical exam. The staff member signs to declare the truth of the information provided and to permit the use of their personal data to ensure safety at their institution.

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    Staff Health Form

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    This document is a staff health form that collects demographic information, medical history, immunization history, and results of a physical assessment. It gathers the staff member's name, age, gender, date of birth, address, phone number, email, education level, work history, history of medical conditions and allergies, record of immunizations received, results of tuberculosis tests, physical measurements, and notes on the physical exam. The staff member signs to declare the truth of the information provided and to permit the use of their personal data to ensure safety at their institution.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    24 views3 pages

    Staff Health Form: Demographic Profile

    Uploaded by

    Aaron Jay Mondaya
    This document is a staff health form that collects demographic information, medical history, immunization history, and results of a physical assessment. It gathers the staff member's name, age, gender, date of birth, address, phone number, email, education level, work history, history of medical conditions and allergies, record of immunizations received, results of tuberculosis tests, physical measurements, and notes on the physical exam. The staff member signs to declare the truth of the information provided and to permit the use of their personal data to ensure safety at their institution.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    of 3

    Staff Health Form

    Demographic Profile
    Name: Age: Gender:
    Date of Birth:
    Address:

    Street Barangay Province/City


    Phone Number:
    Email:
    Educational Attainment (please check the box of your chosen answer)

    Primary Level Secondary Level Tertiary Level

    If you have finished tertiary, please include your course:

    Working History
    Please specify:

    Health History
    Please answer the following honestly:
    Yes No Please give further details if you
    answered “yes”
    Do you have any allergy?
    Asthma
    Diabetes
    High blood pressure
    Congenital heart disease
    Seizure disorder
    Others

    Immunization Check
    Please check the box if you already received a vaccine for that certain disease.
    Tetanus Chickenpox
    Hepatitis A Rotavirus
    Hepatitis B Influenza
    Polio Pneumococcal virus
    Measles Meningococcal virus
    Mumps
    Mantoux Test for Tubercolosis:

    1st step date Result

    2nd step date Result


    Physical Assessment

    Height: Weight: BMI: BP:


    Physical Examination (please check your chosen answer, if you checked the not normal, please explain further):
    Normal Not Normal Please give more details
    Skin
    Heart
    Kidney
    Lungs
    Eyes
    Ears
    Mouth
    Left hand
    Right hand
    Left foot
    Right foot
    Fingers
    Toes
    Musculoskeletal
    Functioning
    Back/spine
    Neurological
    Psychiatric

    Examining Physician’s Signature


    Over Printed Name

    I hereby declare that all of the data I stated above


    are true. Further, I also give permission to use my
    personal data in order to improve and assure the
    Staff’s Signature Over safety of the students and staffs in this particular
    Printed Name institution I am working/ will be working in.

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