Indicate if you are suffering from or have a history of the following conditions:

CONDITION	YES	NO	CONDITION	YES	NO
DIABETES			BACK PAIN
KIDNEY DISEASE			PAIN ON URINATION
HEART DISEASE			CHANGE IN BOWEL HABITS
HIGH BLOOD PRESSURE			INCREASED THIRST
ARTHRITIS			PERSISTENT SORES/LUMPS
MENTAL ILLNESS			INFECTIOUS DISEASE
EPILEPSY/CONVULSIONS			CANCER
SWELLING IN THE EXTREMITIES			ANY OTHER PHYSICAL DISABILITY
ALLERGIES

TURBERCULOSIS QUESTIONNAIRE

Indicate if you have been experiencing the following conditions

CONDITION	YES	NO	CONDITION	YES	NO
PERSISTENT COUGH FOR < 3 WEEKS			UNEXPLAINED WEIGHT LOSS
BLOOD IN THE SPUTUM			LOSS OF APPETITE
LOSS OF APPETITE			HOARSENESS
NIGHT SWEATS			FATIGUE
CHEST PAIN			FEVER

Have you had a positive PPD reading? Yes No

Are you under the care of a physician? Yes No Reason dddd

Do you take depressants, stimulants, narcotic drugs that alter your behavior? Yes No

Do you take prescription medications? Yes No No If yes, which medications? dddd

If required in your position, would you be willing to have screening test for drugs/alcohol done on your blood /urine as a condition for employment? Yes No

Have you had any operations or hospitalization for illnesses past 5 years? Reason: screening_test_explain?>

Name of Physician: name_of_physician?> Telephone: tel_of_physician?>

I have read the above and declare that I have had no injury, illness or ailment other than as specifically identified. I certify that I am not habituated or addicted to any depressants, stimulants, narcotics, drugs, alcohol or other substances that may alter my behavior.

Employee Signature: Date:
RN Signature: Date: