Xincon Annual Physical (Compliance)

XINCON HOME HEALTH CARE SERVICES, INC.

EMPLOYEE HEALTH ASSESMENT
ANNUAL HEALTH ASSESMENT
OTHER:
First Name
Last Name
Name:
Title:
Sex:
Street Address
Apt/Unit#
City
State
Zip Code
Full Street Address:
Full Address Part 2:
SS#:
Marital Status:
Emergency Contact:
Relationship:
Telephone No:
Name of your Physician:
Telephone No:
Address:
INDICATE BELOW ILLNESS EXPERIENCED BY YOU OR FAMILY

CONDITION
DIABETES

YESNO
KIDNEY DISEASE

YESNO
HEART DISEASE

YESNO
HIGH BLOOD PRESSURE

YESNO
ARTHRITIS

YESNO
TUBERCULOSIS

YESNO
MENTAL ILLNESS

YESNO
EPILEPSY/CONVULSIONS

YESNO
CANCER

YESNO
MIGRAINE HEADACHES

YESNO
FAINTING OR DIZZINESS

YESNO
WEIGHT GAIN/LOSS 15+ LBS.OR MORE

YESNO
CHANGE IN ENERGY LEVEL

YESNO
DO YOU SMOKE?

YESNO
DO YOU DRINK ALCOHOLIC BEVERAGES?

YESNO
If yes how much?
DO YOU TAKE DEPRESSANTS, STIMULANTS, AND NARCOTIC DRUGS THAT ALTER YOUR BEHAVIOR?

YESNO
If yes, which medications?
DO YOU TAKE PRESCRIPTION MEDICATIONS?

YESNO
If yes which medications?
FREQUENT COUGH

YESNO
BLOOD IN SPUTUM

YESNO
SHORTNESS OF BREATH

YESNO
CHEST PAIN/PRESSURE IN CHEST

YESNO
SWELLING IN LEGS AND FEET

YESNO
PAIN IN CALF WHEN WALKING

YESNO
CHANGE IN BOWEL HABITS

YESNO
BACK PAIN

YESNO
PAIN WHEN URINATING/BLOOD IN URINE

YESNO
INFECTIOUS DISEASE

YESNO
INCREASED THIRST

YESNO
PERSISTANT SORES OR LUMPS

YESNO
I have read the above and declare that I have had no injury, illness or ailment other than as specifically identified. I certify that I am free from habituation or addiction to any legal or illicit drugs such as depressants, stimulants, narcotics, alcohol, or any other substances that may alter my behavior.
Signature: Date:

Clear
Signature: Date:

MonthDayYear
Date
Doctor/RN Signature

Clear
License #:
Doctor/RN Signature Date

MonthDayYear
Date
Should be Empty: