Medical Surveillance Form

ARKANSAS STATE UNIVERSITY, MEDICAL SURVEILLANCE PROGRAM
General Information
Full Name: ____________________________________________________________________________
Date of Birth: ________________
What possible hazardous exposures exist in your position/research?
Animals: □ Lab animals (mice/rats/guinea pigs, etc.) □ Birds
□ Farm animals □ Wild animals □ Insects
□ Aquatic animals
Human or primate: □ Blood □ Tissues, fluids or other potentially infectious materials
□ Human cell culture
Environmental: □Chemicals □ Dust □ Noise
Will you be exposed to animals that may have rabies? □ Yes □ No
Will you be involved in recombinant DNA or human gene transfer research? □ Yes □ No
Are you pregnant or planning to become pregnant in the near future? □ Yes □ No
Medical History □ I have no significant medical history
Current medications: ___________________________________________________________ □ None
□ Anemia □ Hearing Problems □ Rheumatic/Scarlet Fever
□ Arthritis □ Heart Problems □ Seizures/Epilepsy
□ Cancer □ Heat Stroke □ Stomach/Bowel Problems
□ Diabetes □ High Blood Pressure □ Tuberculosis
□ Difficulty Smelling □ Joint or Muscle Problems □ Vision Problems
□ Dizziness or Fainting □ Kidney or Liver Disease
□ Other:_____________________________________________________________________________
Do you have a medical condition that impairs your immune system (HIV, chemotherapy, radiation, etc.)?
□ Yes □ No
Allergy History
Do you currently have or have you ever had any of the following conditions?
Asthma/Wheezing? □ Yes □ No If yes, when? _____________________
Chronic cough/Bronchitis? □ Yes □ No If yes, when? _____________________
Eczema/Skin rash? □ Yes □ No If yes, when? _____________________
Hay fever/Seasonal allergies? □ Yes □ No If yes, when? _____________________
Itchy, irritated eyes? □ Yes □ No If yes, when? _____________________
Shortness of breath? □ Yes □ No If yes, when? _____________________
Other lung/breathing problems? □ Yes □ No If yes, when? _____________________
Allergies to food or medicine? □ Yes □ No
If yes, list:____________________________________________________________________________
Allergies to pollen, grass, weeds, trees, yeas or molds? □ Yes □ No
If yes, list:____________________________________________________________________________
Allergies to latex, chemicals or other substances? □ Yes □ No
If yes, list:____________________________________________________________________________
Allergies to animals? □ Yes □ No
If yes,list:____________________________________________________________________________
Immunization History
Tetanus: Td _______ or Tdap _________
Hepatitis B ________ (date of series completion if there is risk of exposure to human or primate derived
materials)
Rabies: _________ (if applicable)
The above information is accurate to the best of my knowledge.
______________________________________ _________________________