Section 3: Medical History:
Name of your Primary Care Physician:
Date of Last Visit:
Location of Primary Care Physician:
Other Specialists involved in your care (list names and locations):
The following questions address possible health concerns related to your work with laboratory animals in Faculty of Arts and Sciences animal facilities:
1. Do you currently smoke tobacco? No or Yes.
2. Have you smoked tobacco in the past 12 months? No or Yes.
3. Have you experienced any of the following symptoms: eye burning? nasal congestion? skin itching? hives? cronic cough? wheezing? shortness of breath? anaphylaxis?
Do you take medication to control any of the above symptoms? No or Yes. If yes, please list.
When did your symptoms begin? Childhood or Adult.
4. Have you experienced any of these symptoms with exposure to any of the following items?
a. Animals? No or Yes. If yes, please specify the species that cause symptoms and describe your symptoms.
b. Latex products? No or Yes. If yes, please tell us which symptoms you experience.
c. Other workplace items? No or Yes. If yes, please explain.
d. Have you had skin allergy testing?
i. Skin test? No or Yes. If yes, results:
ii. Other test? No or Yes. If yes, type of test and results.
e. If you take any medication for the above problems, please list.
5. Muscle and Joint conditions:
a. If you have had weakness, pain, stiffness, or restrictions in your muscles or joints, please check off the affected body parts: shoulders? elbows? wrists/hands? hips? knees? ankles? neck? lower back?
b. If you have checked any of the above items, please describe the problem and any treatment you received.
c. If you take any medications for the above problems, please list.
6. Other significant medical problems:
a. Have you ever been told you have an illness that will make you more susceptible to other illnesses? No or Yes. (You may choose to leave this section blank if you prefer and discuss these matters with the occupational health specialist).
b. Do you have any other medical concerns that might interfere with your ability to do your job that you would like to discuss with an occupational health physician? No or Yes.