Health Screening Questionnaire

Name: ______________________________________________ Birth Date:________________

Emergency Contact: ____________________________________________________________
Relationship: _________________________________________ Phone:___________________
Please answer the following questions.
1.) In the past 24 hours, have you had any of the following (check all that apply):
___Vomiting ___Cough ___Rash ___Fever ___Diarrhea ___Runny Nose ___None
2.) In the past three weeks, have you been exposed to anyone with the following (check all that apply):
___Measles ___Mumps ___Varicella (Chicken Pox) ___No exposure
3.) Have you been exposed to Tuberculosis (TB) in the last three months? ___Yes ___No
4.) How would you describe your overall health? ___Excellent ___Good ___Fair ___Poor
5.) If your are sensitive to a hospital environment for some reason (i.e. past hospitalization or traumatic
experience) or are prone to seizures or fainting, please indicate that below:
___________________________________________________________________________________
___________________________________________________________________________________
Immunization Record:
1.) Mantoux/TB Test (within last 12 months) Date:__________________
Attach a copy of the Maxtoux/TB results, or chest x-ray if positive reactor.
2.) Measles/Mumps/Rubella (MMR) Date:__________ Date:__________
3.) Measles (Rubeola) Date:__________
4.) Polio Vaccine Date:__________
5.) Tetanus or Tetanus Diphtheria Date:__________
6.) Hepatitis B Vaccine (optional, not required for observation experience) Date:_________
I certify the information given regarding my health to be accurate and to the best of my knowledge.
NOTE: This form must be signed by the parent/guardian and brought to the Human Resources Department
the day of shadow experience. The minor will not be permitted to participate in the noted program if they fail
to bring this form with them.
__________________________________________ ________________________
Job Shadow Participant Signature Date

__________________________________________ ________________________
Parent/Guardian Signature Date

__________________________________________ ________________________
Human Resources Representative Date

IF YOU ARE UNDER THE AGE OF 18, PARENT OR LEGAL GUARDIAN MUST COMPLETE THIS FORM.