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

KIDNEY DISEASE

HEART DISEASE

HIGH BLOOD PRESSURE

ARTHRITIS

TUBERCULOSIS

MENTAL ILLNESS

EPILEPSY/CONVULSIONS

CANCER

MIGRAINE HEADACHES

FAINTING OR DIZZINESS

WEIGHT GAIN/LOSS 15+ LBS.OR MORE

CHANGE IN ENERGY LEVEL

DO YOU SMOKE?

DO YOU DRINK ALCOHOLIC BEVERAGES?

If yes how much?

DO YOU TAKE DEPRESSANTS, STIMULANTS, AND NARCOTIC DRUGS THAT ALTER YOUR BEHAVIOR?

If yes, which medications?

DO YOU TAKE PRESCRIPTION MEDICATIONS?

If yes which medications?

FREQUENT COUGH

BLOOD IN SPUTUM

SHORTNESS OF BREATH

CHEST PAIN/PRESSURE IN CHEST

SWELLING IN LEGS AND FEET

PAIN IN CALF WHEN WALKING

CHANGE IN BOWEL HABITS

BACK PAIN

PAIN WHEN URINATING/BLOOD IN URINE

INFECTIOUS DISEASE

INCREASED THIRST

PERSISTANT SORES OR LUMPS

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:

Date

Doctor/RN Signature

License #:

Doctor/RN Signature Date

Date