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URGENT: Please contact any location below to schedule your Employee Health Evaluation.
Please allowed 1.0 to 1.5 hours for this appointment.
REQUIRED: Inform Concentra that you are with Northside Hospital, walk-ins are not allowed for new hires.
Sandy Springs Urgent Care
6334 Roswell Road, NE
Suite C
Sandy Springs, GA 30328
Hours of Operation
(Mon. - Fri.) 8:00 am – 7:00 pm
Phone: 678.812.2277
Norcross Jimmy Carter
6475 Jimmy Carter Blvd.
Suite 200
Norcross, GA 30071
Hours of Operation
(Mon. - Fri.) 7:30 am - 6:00 pm
Phone: 770.242.7744
Marietta
220 N. Cobb Pkwy.
Suite 400
Marietta, GA 30062
Hours of Operation
(Mon. - Fri.) 7:30 am - 6:00 pm
Phone: 770.424.7125
Johns Creek
10820 Abbotts Bridge Road
Suite 3000
Duluth, GA 30097
Hours of Operation
(Mon. - Fri.) 8:00 am - 5:30 pm
Phone: 770.441.0444
Lawrenceville
755 Lawrenceville Suwanee Road
Suite 1600
Lawrenceville, GA 30043
Hours of Operation
(Mon. - Fri.) 7:30 am - 8:00 pm
Phone: 770.995.1500
Morrow
1500 Mount Zion Road
Morrow, GA 30260
Hours of Operation
(Mon. - Fri.) 7:30 am - 6:00 pm
Phone: 678.422.8824
Midtown
688 Spring St NW Atlanta,
GA 30308
Hours of Operation
(Mon. - Fri.) 7:30 am - 7:00 pm
Phone: 404.881.1155
Revised: 09/2020
(Patient Must Present Photo ID at time of Service)
Authorization for Examination or Treatment
Patient Name: ______________________________ Drivers License #: _____________________
Date of Birth: ______________________________ Location to report to: _____________________
Employer: NORTHSIDE HOSPITAL 1000 Johnson Ferry Rd Atlanta, GA 30342
PREPLACEMENT PHYSICAL EXAM:
X Physical Pre-placement
X Non-Regulated Drug Screen Pre-placement (Collect)
X T Spot
X Influenza (Flu Shot)
X Fit for Duty Level 2
X Blood Collect
___________________________________
___________________________________
___________________________________
Use employee forms for T- Spot, MMR, UDS Collect &
Physical. PT must sign both Panel and
Acknowledgment Form. Use DL # instead of SSN. Us
e
NSH version for Fit for Duty Physical. Fax all ppwk/
results to Northside Hospital.
404-851-8765.
S
end full chart to Northside Hospital
* Due to the nature of these specific services, only
the patient and staff are allowed in the
testing/treatment area. Please alert your employee so
that they can make arrangements for children or
others that might otherwise be accompanying them to
the medical center.
Authorized by: _________________________
Title:________________________________
Concentra now offers urgent/immediate medical care services for non-work related illness and injury.
We accept many insurance plans.
Please print a copy to bring with you to the appointment.
Please make sure to hydrate the day before your exam.
***Please email HR.ServiceCenter@northside.com with your appointment date and time***
Revised: 09/2020
Interchange
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Revised: 09/2020
Northside Hospital
N/A
Shahnaz Lakhani
404-851-8387
1000 Johnson Ferry Road
Atlanta
GA
30342
N/A
N/A
HE
PATITIS B VACCINATION DECLINATION FORM
I understand that due to my occupation, I may be at risk of acquiring Hepatitis B if I am
exposed to a patient's blood or body fluids. I have/have not had an occupational exposure. I
understand that according to OSHA, an estimated 6,900 to 7,400 cases of Hepatitis B virus
infection occurs each year following occupational exposure.
I have been given the opportunity to be vaccinated with Hepatitis B vaccine, at no charge to
myself. With this information and counseling, I have elected NOT to receive the Hepatitis B
vaccination series. I also understand that should I decide, at a later date while employed here,
to receive the Hepatitis B vaccination series, it will be available at no charge to me.
My signature below acknowledges that:
I have read or someone has read to me this form, and I understand it.
All of my questions regarding the Hepatitis B vaccine have been answered. Based on
this information I will check one of the following:
1. __________I have already received the Hepatitis B vaccine series.
2. __________I have tested positive in the past for Hepatitis B surface antigen.
3. __________I decline at present due to pregnancy.
4. __________I do not wish to receive the Hepatitis B vaccine at this time.
_______
__________________________/__________________ ______________________
Signature of Employee Last 4# of SSN Date
_______
_____________________________________________ ______________________
Signature Date
Employee Health Nurse/Northside Hospital Representative
Revised: 09/2020
PRE-EMPLOYMENT/POST-OFFER QUESTIONNAIRE
INSTRUCTIONS: This questionnaire must be completed by all newly hired employees for medical
examination purposes
. All applicable questions must be answered.
SECTION I:
JOB TITLE
NAME
SOCIAL SECURITY #
HOME ADDRESS
DEPT NAME
CELL PHONE #
AGE GENDER
RELATIONSHIP
ZIP CODE
START DATE:
Please explain all YES answers and include dates of treatment.
6. Do you smoke? How much? For how long?
Page 1 of 4
Revised: 02/12/2021
Have you had the following immunizations or childhood diseases?
YES NO
1. Measles, Mumps, Rubella (MMR) Vaccine
2. Hepatitis Vaccine
3. Tetanus
4. Chicken Pox
DATE
SECTION III:
YES NO
1.
2.
3.
4.
5. Have you ever been addicted to or dependent upon any other types of drugs or narcotics?
Have you ever had a positive TB Skin Test?
1a. If so, did you take INH treatment?
Have you ever had a BCG vaccine?
(This is a vaccine for TB usually given to people living in a foreign country.)
Are you allergic to any drugs, medications, or other substances?
Have you ever been treated for or diagnosed as an alcoholic?
CITY & STATE
DATE OF BIRTH
EMAIL
NOTIFY IN CASE OF EMERGENCY
EMERGENCY CONTACT #
SECTION II:
5. COVID Vaccine
YES NO YES NO
1. Cerebral palsy 16. Arthritis
2. Multiple Sclerosis 17. Kidney Problems
3. Muscular Dystrophy 18. Epilepsy or Seizures
4. Vision Problems 19. Skin Rashes
5. Heart Disease 20. Hemophilia
6. Rheumatic Fever 21. Leukemia or Cancer
7. High Blood Pressure 22. Headaches
8. Anemia 23. Fainting or Dizziness
9. Chest Pains 24. Backache or Back Injury
10. Circulatory Problems 25. Neck or Shoulder Injury
11. Tuberculosis 26. Knee Injury
12. Asthma 27. Wrist Injury or Carpal Tunnel
13. Sickle Cell Anemia 28. Diabetes
14. Hepatitis 29. Hernia
15. Ulcers 30. Thyroid Disorder
Please ex
plai
n all Y
ES answers
from
from above. Include approximate dates of treatment.
When?
Where?
Cleared by your Doctor
Not Cleared
Why Not?
SECTION IV :
Have you ever had or been treated for any of the following medical problems?
Where?
Cleared by your Doctor
Not Cleared
Why Not?
When?
Where?
Cleared by your Doctor
Not Cleared
Why Not?
When?
Page 2 of 4
Revised: 02/12/2021
Please explain all YES answers and include dates of treatment.
14. List all physicians, psychiatrists, and/or psychologists who have treated you within the past 5 years:
15. Please list all medications you are taking or have taken in the past 30 days. Include all pain pills and/or narcotics.
Page 3 of 4
SECTION V:
Please answer all the following questions:
YES NO
1. Are you presently under a physician's care for any medical or psychiatric condition?
2.
Do you have any physical limitations, handicaps, or disabilities that would prevent you
from performing the essential functions of your job?
3. If so, do you require any accommodations to assist you in performing your job?
4. Have you ever been treated or hospitalized for a psychiatric or mental health condition?
5. Have you ever or are you currently undergoing psychotherapy?
6. Have you EVER had a back injury?
7. Have you ever had a job-related accident or injury?
8. Have you ever lost time from work due to a major illness or injury?
9.
Have you ever received or applied for Worker's Compensation benefits for any
occupational injury?
10. Have you ever been diagnosed with a communicable disease such as HIV or Hepatitis B?
11. Are you pregnant at this time?
12.
Do you anticipate any surgery, hospitalization, or major medical treatment within the next
12 months?
13. Have you been hospitalized in the past 1O years?
Revised: 02/12/2021
Do you work in an area with frequent contact with blood, blood products, or blood contaminated equipment?
YES NO .These areas are considered high risk for exposure to Hepatitis B.
Hepatitis B vaccine is available to ALL employees free of charge. The vaccine is strongly encouraged for employees
who answered YES to the question above. Additional information is available at your request from the Employee
Health Nurse.
PLEASE READ CAREFULLY AND SIGN:
I have received a conditional offer of employment at Northside Hospital. I understand that all individuals receiving
offers of employment are required to complete a medical history and examination. The purpose of this
questionnaire and the examination is to determine (1) my ability to perform the essential functions of the job that I
have been offered, (2) whether I require any accommodations to perform those essential job functions and (3)
whether I can perform those essential job functions without presenting a threat to the health and safety of myself
or others.
I understand that this questionnaire and examination are for the limited purpose described above and are not
intended to provide a comprehensive screening for all medical conditions. I have been encouraged to establish a
relationship with a primary care physician to address my own healthcare needs. I release Northside Hospital and
all persons performing this limited purpose examination or obtaining such information from liability for failure to
detect or disclose any medical condition.
I understand that the federal Genetic Information Nondiscrimination Act (GINA) prohibits employers from asking
questions pertaining to genetic testing or family medical history. I have not disclosed any health condition or
potential health condition based on genetic testing or family history.
I agree to complete any necessary authorization forms to obtain information from any hospital, clinic or physician
necessary to make the determinations described above. I understand that my refusal to complete such
authorization forms may be considered cause for withdrawal of the conditional offer or discharge from
employment.
I certify that all information provided in this questionnaire is true and correct to the best of my knowledge. I
understand that any falsification or significant omission of any information requested herein can be considered
sufficient cause for discharge without prior warning at any time during my employment or assignment at Northside
Hospital.
I also understand that the information in this questionnaire and collected in the medical examination will be kept
strictly confidential in a separate employee health file, apart from my personnel file. The information will be
available only for the purposes authorized by the Americans with Disabilities Act, including disclosure to my
manager or supervisor on an as needed basis regarding necessary restrictions or accommodations.
I further understand that if I am injured at work and medical treatment other than first aid becomes necessary, I
must accept the services of a physician listed on the Panel of Physicians for Worker's Compensation. If I choose a
physician not listed on the Panel, I will be liable for those medical expenses.
EMPLOYEE SIGNATURE DATE
TO BE FILLED OUT BY HEALTH CARE PROVIDER:
Height Weight B/P PPD Or Chest X-Ray
Hep B Series Varivax Rubella Rubeola
Varicella Urine for Drug Screen Shown W/C Panel
Health Care Provider Signature
Date
***If BP is >160/100 a 2
nd
BP is required***
B/P (2) B/P Notes
Page 4 of 4
Revised: 02/12/2021
COVID Vaccine (If vaccinated within the last 30 days, do not order QFT/Tspot )
Comments:
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Completed 5 June 2021

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