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. ______________________________________ _________________________