Bronson South Haven Occupational Medicine 950 South Bailey Ave, Suite 1 South Haven, MI 49090 Phone: (269) 639-2787 Fax: (269) 639-2785 Email: [email protected] Occupational Medicine Patient Registration

Employee Name Date of Birth Date Phone Number Email SSN# Gender Male Female Marital Status Single Married Separated Divorced Widowed Ethnicity African American Asian Hispanic Native American Caucasian Other Home Address City State Zip Employer Supervisor Employer Phone New Hire Current employee Emergency contact Name Relationship Phone I, the undersigned, acknowledge that I am presenting for an Occupational Medical test(s), examination or medical treatment at the direction of my possible, current, or previous employer. I understand it is my responsibility to communicate with my employer regarding authorization for any Occupational Medical testing and/or treatment that I will receive at Bronson South Haven Occupational Medicine. If authorization from my employer is not obtained or otherwise not required, I accept responsibility for all charges incurred through Occupational Medicine with payment due at the time of service. Bronson South Haven DOES NOT submit any billing to your health insurance carrier for Occupational Medical services. I understand that if I request reimbursement from my health insurance carrier, I am responsible for submitting any Occupational Medicine charges that I incurred to my health insurance carrier, depending on my health insurance policy. I also acknowledge and understand that any Occupational Medical examination and testing is at the request of my employer or related to my employment and does not take the place of any type of examination or health screening with my own physician or primary care provider.

I authorize the staff of Bronson South Haven Occupational Medicine to obtain any needed medical records via the electronic medical record system and to release my medical information regarding any testing, diagnosis, treatment and prognosis as it relates to my current or future employment to the following person/people: Employer (REQUIRED) Primary Care Provider Phone Emergency contact as listed above Other Relationship Other Relationship This authorization is valid until such time that I request a person or persons to be added or deleted from the above list. Unless otherwise advised, this medical release authorization will be valid for one year.

Check box for consent for drug screening (pre-employment, post-accident, random, reasonable suspicion) I understand that the test being performed is for the purpose of detecting the presence or absence of illicit drugs and drug products. I authorize Bronson South Haven Occupational Medicine to perform this Drug Analysis and to release the results of this test to the employer listed above. I agree to hold BSH Occupational Medicine harmless for any actions that may be taken as a result of this test.

I acknowledge that understand and received a copy of the Bronson South Haven Notice of Privacy Practices.

Signature Date Printed name Witness Date

BSH_OccMed_registration.pdf Revised 10/8/15 Bronson South Haven Occupational Medicine 950 South Bailey Ave, Suite 1 South Haven, MI 49090 Phone: (269) 639-2787 Fax: (269) 639-2785 Email: [email protected]

Occupational Medicine Health History

Name: DOB: Date of exam: Please complete every question and check the appropriate line if you have or had any of the following health issues: Previous Medical Problems: NONE High blood pressure Diabetes Heart disease Asthma Seizures Stroke Tuberculosis Kidney disease Depression Sleep apnea Cancer- type Other Previous Surgeries: NONE Appendectomy C-section Open heart Cardiac cath or stent Hernia Tonsils Joint replacement Hysterectomy Fracture repair Gall Bladder Back or neck Knee Shoulder Other Medications Name Dose Frequency Name Dose Frequency NONE

Allergies: No known allergies Penicillin Sulfa Codeine Latex Egg Nut Other Social: Non-smoker Smoker Other tobacco use Drinks per week Review of System Please check the appropriate box if you have any of the following health issues or conditions: Constitutional NONE Activity change Appetite change Chills Excessive sweating Fatigue Fevers Unexpected weight change Head, Ears, Nose NONE Congestion Dental problems Drooling Ear discharge Ear Pain and Throat Facial swelling Hearing loss Mouth sores Nosebleeds Postnasal drip Nasal drainage Sinus pain Sneezing Sore throat Tinnitus Trouble swallowing Voice changes Eyes NONE Discharge Itching Pain Redness Photophobia Visual disturbance Respiratory NONE Apnea Chest tight Choking Cough Short of breath Stridor Wheezing Cardiovascular NONE Chest pain Leg swelling Palpitations Gastrointestinal NONE Abdominal distention Abdominal pain Anal bleeding Blood in stool Constipation Diarrhea Nausea Rectal pain Vomiting Endocrine NONE Temperature intolerance Excessive thirst Increased appetite Increased urination Genitourinary NONE Difficulty urinating Painful urination Uncontrolled urination Flank pain Change in frequency Genital sore Blood in urine Urgency Decreased urine output Musculoskeletal NONE Joint pain Back pain Gait problem Joint swelling Muscle pain Neck pain Skin NONE Color change Pale Rash Wound Allergy/Immune NONE Environmental allergies Food allergies Immunocompromised Neurological NONE Dizziness Facial asymmetry Headaches Light headed Numbness Seizures Speech problems Syncope Tremors Weakness Lymphatic NONE Enlarged lymph nodes Bleeding Easy bruising Behavior/Psych NONE Agitation Behavior problem Confusion Decreased concentration Depression Hallucinations Hyperactive Anxiety Self-injury Sleep disturbance Suicidal ideas Females only Are you currently pregnant? No Yes Not sure

Signature:

Please use other side for listing additional information. BSH_OccMed_healthhx.pdf Revised 12/22/16 Bronson South Haven Occupational Medicine 950 South Bailey Ave, Suite 1 South Haven, MI 49090 Phone: (269) 639-2787 Fax: (269) 639-2785 Email: [email protected]

OSHA Respirator Medical Evaluation Questionnaire (Mandatory) Appendix C to Sec. 1910.134

To the employer: Answers to questions in Section 1, and to question 9 in Section 2 of Part A, do not require a medical examination.

To the employee: Your employer must allow you to answer this questionnaire during normal working hours, or at a time and place that is convenient to you. To maintain your confidentiality, your employer or supervisor must not look at or review your answers, and your employer must tell you how to deliver or send this questionnaire to the health care professional who will review it.

Part A. Section 1 The following information must be provided by every employee who has been selected to use any (MANDATORY) type of respirator. (Please print)

Name DOB Today’s date

Age Sex Male Height Weight Female Department Job title

A phone number where you can be reached by the health care professional who reviews this questionnaire (include the Area Code): The best time to phone you at this number

Has your employer told you how to contact the health care professional who Yes will review this questionnaire? No Would you like a copy of this questionnaire and any other supporting Yes documents for your records? No

Check the type of respirator you will use (you can check more than one category): N, R, or P disposable respirator (filter-mask, non-cartridge type only) Other type (for example, half or full face-piece type, powered-air purifying, supplied-air, self-contained breathing apparatus) Have you worn a respirator? Yes No If "yes," what type(s): N, R, or P disposable respirator (filter-mask, non-cartridge type only) Other type (for example, half or full face-piece type, powered-air purifying, supplied-air, self-contained breathing apparatus)

Page 1 of 4 BSH_OccMed_MEQ_initial.pdf Revised 12/22/16 Bronson South Haven Occupational Medicine 950 South Bailey Ave, Suite 1 South Haven, MI 49090 Phone: (269) 639-2787 Fax: (269) 639-2785 Email: [email protected]

OSHA Respirator Medical Evaluation Questionnaire (Mandatory) Appendix C to Sec. 1910.134

Name

Part A. Section 2 Questions 1 through 9 below must be answered by every employee who has been selected to use any type of respirator. Please check “Yes” or “No” for your response.

Question Yes No 1. Do you currently smoke tobacco, or have you smoked tobacco in the last month 2. Have you ever had any of the following conditions? a. Seizures b. Diabetes (sugar disease) c. Allergic reactions that interfere with your breathing d. Claustrophobia (fear of closed-in places) e. Trouble smelling odors 3. Have you ever had any of the following pulmonary or lung problems a. Asbestosis b. Asthma c. Chronic bronchitis d. Emphysema e. Pneumonia f. Tuberculosis g. Silicosis h. Pneumothorax (collapsed lung) i. Lung cancer j. Broken ribs k. Any chest injuries or surgeries l. Any other lung problem that you've been told about 4. Do you currently have any of the following symptoms of pulmonary or lung illness? a. Shortness of breath b. Shortness of breath when walking fast on level ground or walking up a slight hill or incline c. Shortness of breath when walking with other people at an ordinary pace on level ground d. Have to stop for breath when walking at your own pace on level ground e. Shortness of breath when washing or dressing yourself f. Shortness of breath that interferes with your job g. Coughing that produces phlegm (thick sputum) h. Coughing that wakes you early in the morning i. Coughing that occurs mostly when you are lying down j. Coughing up blood in the last month k. Wheezing l. Wheezing that interferes with your job m. Chest pain when you breathe deeply n. Any other symptoms that you think may be related to lung problems

Page 2 of 4 BSH_OccMed_MEQ_initial.pdf Revised 12/22/16 Bronson South Haven Occupational Medicine 950 South Bailey Ave, Suite 1 South Haven, MI 49090 Phone: (269) 639-2787 Fax: (269) 639-2785 Email: [email protected]

OSHA Respirator Medical Evaluation Questionnaire (Mandatory) Appendix C to Sec. 1910.134

Name

Questions Yes No 5. Have you ever had any of the following cardiovascular or heart problems? a. Heart attack b. Stroke c. Angina d. Heart failure e. Swelling in your legs or feet (not caused by walking) f. Heart arrhythmia (heart beating irregularly g. High blood pressure h. Any other heart problem that you've been told about 6. Have you ever had any of the following cardiovascular or heart symptoms? a. Frequent pain or tightness in your chest b. Pain or tightness in your chest during physical activity c. Pain or tightness in your chest that interferes with your job d. In the past two years, have you noticed your heart skipping or missing a beat e. Heartburn or indigestion that is not related to eating f. Any other symptoms that you think may be related to heart or circulation problems 7. Do you currently take medication for any of the following problems? a. Breathing or lung problems b. Heart trouble c. Blood pressure d. Seizures 8. If you've used a respirator, have you ever had any of the following problems? If you've never used a respirator, check this box ☐ then go to question 9 a. Eye irritation b. Skin allergies or rashes c. Anxiety d. General weakness or fatigue e. Any other problem that interferes with your use of a respirator 9. Would you like to talk to the health care professional who will review this questionnaire about your answers to this questionnaire

Page 3 of 4 BSH_OccMed_MEQ_initial.pdf Revised 12/22/16 Bronson South Haven Occupational Medicine 950 South Bailey Ave, Suite 1 South Haven, MI 49090 Phone: (269) 639-2787 Fax: (269) 639-2785 Email: [email protected]

OSHA Respirator Medical Evaluation Questionnaire (Mandatory) Appendix C to Sec. 1910.134

Name

Questions 10-15 below must be answered by every employee who has been selected to use either a full face-piece respirator or a self-contained breathing apparatus (SCBA). For employees who have been selected to use other types of respirators, answering these questions is voluntary.

Questions Yes No 10. Have you ever lost vision in either eye (temporarily or permanently) 11. Do you currently have any of the following vision problems? a. Wear contact lenses b. Wear glasses c. Color blind d. Any other eye or vision problem 12. Have you ever had an injury to your ears, including a broken ear drum 13. Do you currently have any of the following hearing problems? a. Difficulty hearing b. Wear a hearing aid c. Any other hearing or ear problem 14. Have you ever had a back injury 15. Do you currently have any of the following musculoskeletal problems? a. Weakness in any of your arms, hands, legs, or feet b. Back pain c. Difficulty fully moving your arms and legs d. Pain or stiffness when you lean forward or backward at the e. Difficulty fully moving your head up or down f. Difficulty fully moving your head side to side g. Difficulty bending at your waist h. Difficulty squatting to the ground i. Climbing a flight of stairs or a ladder carrying more than 25 lbs j. Any other muscle or skeletal problem that interferes with using a respirator

For all health care employees, please also complete the Latex Sensitivity Questionnaire.

Patient signature

Page 4 of 4 BSH_OccMed_MEQ_initial.pdf Revised 12/22/16 Bronson South Haven Occupational Medicine 950 South Bailey Ave, Suite 1 South Haven, MI 49090 Phone: (269) 639-2787 Fax: (269) 639-2785 Email: [email protected]

Latex Allergy Questionnaire

Name: DOB: Date of visit:

Risk Factor Assessment/Exposure History Yes No Are you a health care worker? Do you wear latex gloves regularly or are you otherwise exposed to latex regularly? Do you have a history of eczema or other rashes on your hands? Do you have a medical history of frequent surgeries or invasive medical procedures? Did these take place when you were an infant? Do you have a history of "hay fever" or other common allergies? Do your fellow workers wear latex gloves regularly? Do you take a beta-blocker medication? Check any foods below that cause hives, itching of the lips or throat, or other symptoms when you eat or handle them: avocado apple pear celery carrot hazelnut kiwi papaya pineapple peach cherry plum apricot banana melon chestnut nectarine grape fig passion fruit tomatoes potatoes

Contact Dermatitis Assessment: (for patients who wear latex gloves frequently) Yes No Do you have rash, itching, chapping, cracking, scaling, or skin weeping from latex glove use? Have these symptoms recently changed or worsened? Have you used different brands of latex gloves? If so, have your symptoms persisted: Have you used non-latex gloves? If so, have you had the same or similar symptoms as with latex gloves? Do these symptoms persist when you stop wearing all gloves?

Contact Urticaria (Hives) Assessment: (for patients who wear latex gloves frequently) Yes No When you wear or are around others wearing latex gloves do you get hives, red itchy swollen hands within 30 minutes or, "water blisters" on your hands within a day?

Aerosol Reaction Assessment: When you wear or are around others wearing latex gloves, have you noted any: Itchy, red eyes, fits of sneezing, runny or stuffy nose, itching of the nose or palate: Shortness of breath, wheezing, chest tightness or difficulty breathing? Other acute reactions, including generalized or severe swelling or shock

History of Reactions Suggestive of Latex Allergy: Yes No Do you have a history of anaphylaxis or of intra-operative shock? Have you had itching, swelling or other symptoms following dental, rectal or pelvic exams? Have you experienced swelling or difficulty breathing after blowing up a balloon? Do condoms, diaphragms or latex sexual aids cause itching or swelling? Do rubber handles, rubber bands or elastic bands or clothing cause any discomfort?

BSH_OccMed_latexform.pdf Revised 12/22/2016