# 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.  
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_