HEALTH STATEMENT
Your Name (required)
I hereby attest that the state of my health is such that it will enable me to perform the duties of a health care professional. I further specifically attest that I am free of any and all potentially contagious diseases including, but not limited to those listed below:
AIDS, Anthrax, Chickenpox, Cholera, Diphtheria, Encephalitis, Influenza, Hepatitis A/B/C, Leprosy, Leptospirosis, Malaria, Measles (Rubeola), Meningitis, Mononucleosis, Mumps, Whopping cough, Plague, Poliomyelitis, Psittacosis, Rabies, Smallpox, Tetanus, Tularemia, Tuberculosis, Typhoid, Rubella (German measles), Rocky Mountain spotted fever
TB TARGETED MEDICAL QUESTIONNAIRE
1. Have you ever had a positive TB skin test or history of TB infection? Yes No
If the answer is YES, please answer the following questions:
2. Have you ever had the BCG (bacille Calmette-Guerin) TB vaccine? Yes No
3. Do you have prolonged or recurrent fever? Yes No
4. Have you recently lost weight? Yes No
5. Do you have a chronic cough? Yes No
6. Do you cough up blood? Yes No
7. Do you experience sweating at night? Yes No
8. Do you have any of the following risk factors which may substantially increase your risk of TB?
Silicosis (lung disease) Gastrectomy Intestinal bypass Weight 10% or more less than ideal body weight Chronic renal disease Diabetes mellitus Prolonged high dose corticoid steroid therapy Immunosuppressive therapy Hematological disorder (i.e. leukemia or lymphoma) Exposure to HIV or AIDS Other malignancy None of the above
“By entering my name below and clicking submit, I acknowledge this will serve as my electronic signature.”
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