Annual Statement of Physical Health for EI Staff and Providers
Name:
Year:_____________
The health status of all personnel shall be reas
sessed no less than annually to assure that
personnel are free from health impairments which pose potential risk to patients or personnel or
which may interfere with the performance of duties.
How would you describe your present health status?
Very good Good Fair Poor_______
Height: _______ Weight: _______ Blood Pressure: __________
Are you currently under a physician’s care for treatment of any chronic
illness/condition? Yes
No_______
If yes, does this illness/condition impact on your ability to perform your job duties?
Yes No_______
If yes, explain: ______________________________________________________
Did you receive an influenza immunization during the past year?
Yes No________
If no, explain: _______________________________________________________
Do you wish to receive any of the following immunizations?
Hepatitis B Yes No Information Only Already had/current____
Flu Yes
No Information Only Already had/current____
Pneumovax Yes
No Information Only Already had/current____
Varicella Yes
No Information Only Already had/current____
(Chickenpox)
Tetanus (Td) Yes
No Information Only Already had/current____
Tdap Yes
No Information Only Already had/current____
(Tetanus, Diphtheria, Pertussis)
MMR Yes ____ No ____ Information Only ____ Already had/current ____
(Measles, Mumps, Rubella)
Annual Mantoux/PPD Date _____ Result _____ Chest X-ray if indicated Date ____
Do not alter Essex County Forms they have been designed to meet State and Federal requirements.
