<p> HEALTH SCREENING FOR JOB CORPS For Entry and/or Accommodation</p><p>Medical Conditions/Common Illness:</p><p>A. ASTHMA G. PHYSICAL IMPAIRMENT  Type of asthma  Describe impairment  Date of last attack  Capable of ADL?  Current medication(s) and dosage(s)  Appliances?  Hospitalization(s) and/or emergency visit(s)  Frequency of medical follow up needed  Allergies-prescriptions  List any activity restrictions/supervision required  Emergency room visits  Smoking history B. DIABETES H. SEIZURE DISORDERS  Type I or Type II  Type of seizure disorder  Age at onset  Date of onset, frequency of seizures, and last episode  Current medication(s) and dosage(s) – IM and/or po  Current medication(s) and dosage(s)  Special diet/any recommendations  Date of hospitalization(s) and/or emergency room  Height and weight visit(s)  Hospitalizations  Date of last physician visit  Date of last medical visit  Anticonvulsant drug levels if available  Results of fasting blood sugar  Activity restriction(s) and/or supervision required  Results of hemoglobin A1C (last two)  Urine micro albumin  Date of last eye examination C. VISION IMPAIRMENT I. TUBERCULOSIS  Nature of limitations (i.e. caused by injury, birth, progressive?)  Date and results of most recent skin test and chest x-  Impairment in functioning ray  Last eye examination  Medication(s) taken and dosage(s)  Correction of visual deficit with glasses and/or contacts  Date medication(s) were begun D. HEARING IMPAIRMENT J. LEARNING IMPAIRMENT/ADHD  Nature of hearing loss (i.e. caused by accident, birth, disease,  Special needs classes prognosis?)  Type of impairment (emotional, LD)  Last physician visit  Most recent psycho-educational evaluation from  Hearing aids school  Audiogram results  Individual Education Plan (IEP)  Knowledge of sign language and/or reads lips well  Grade equivalent scores  If ADD/ADHD, how determined/treated  Stimulant medication(s), dosage(s), and date begun  Other pertinent vocational and education test results E. ELEVATED BLOOD PRESSURE K. COUNSELING/MENTAL HEALTH  Current medications and dosage  Report from Mental Health counselor/psychiatrist  Date of last physician’s visit  If hospitalized, mental health discharge summary  Current blood pressure (with regular/large cuff)  Special dietary recommendations  Smoker?  Last two sets of height and weight F. SLEEP APNEA L. ALCOHOL and OTHER DRUGS OF ABUSE  Date of last physician visit  History of addiction, any IV use</p><p> Results of sleep study and O2 desaturation %  Treatment  Use of CPAP device  Discharge summary from RX facility  Cardiac abnormalities documented  Length of period of clean and sober  Last two sets of height/weight/blood pressure  Report from counselor </p>