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DRAFT-Physical Health Profile To be completed by the Employee Health Nurse. General information Name: _________________________________ Date of profile: ________________ Date of birth: ____________________________ Employee ID#: ___________________ SIN #: __________________________________ Medicare #: _____________________ Address: ________________________________________________________________ Phone # (home): _________________________ Cell #: __________________________ Email: _________________________________________________________________ Next of Kin: _____________________________Department: _____________________ Date on Staff: ____________________________ Job Classification: ________________ Family Physician: _________________________ Allergies: _______________________________________________________________________ _ _______________________________________________________________________ _ Medications: _______________________________________________________________________ _______________________________________________________________________ _ Physical screening Height
Results
Weight BMI Blood pressure Pulse Glucometer Cholesterol test
 Fasting > 4 hours without food  Non-fasting
History of skin condition (i.e. dermatitis) Yes No a. If yes, please explain and define if the condition is aggravated (i.e. Frequent hand washing/wearing gloves/specific products)
Revised: April 10, 2013- Brenna Coles
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______________________________________________________________ ______________________________________________________________ __ Health care history: Last physical exam? a. 1 year b. 2 years c. 3 years d. 4 years e. 5 or more
Cardiovascular risk: 1) Assess risk for cardiovascular disease. (check all that apply) Contributing risk factors: 55 or older for male, and post-menopausal for women Personal history of heart disease, stroke or diabetes, Family history of heart disease (close blood-relative who had coronary heart disease or stroke before the age of 55 years (for a male relative) or 65 years (for a female relative) Smoking Bowel disease Low aerobic exercise Overweight (BMI >25) High blood pressure (140/90 and above) Abnormal cholesterol levels Diabetes/high blood sugar (5.60+ fast, 7.84+ non) Respiratory risk: 2) Assess risk for lung disease. (check all that apply) Contributing factors: Smoking (cigarettes) No regular exercise Unusual shortness of breath Chronic bronchitis or emphysema (COPD) Asthma Diabetes risk: 3) Assess risk for diabetes: (check all that apply) Contributing factors: Personal history of diabetes Family history of diabetes Overweight (BMI >25) Smoking No regular exercise High blood pressure (140/90 and above) High blood sugar (5.60+ fast, 7.84+ non)
Revised: April 10, 2013- Brenna Coles
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Ergonomics Assessment: Ergonomic assessments are available to all employees who identify the need. Horizon Health is an employer dedicated to promoting safe and healthy working environment and we are committed to reducing and minimizing work-related injury risks.
Immunization form complete:
Yes
No
Fredericton area: N95 Mask Fit testing: Yes No Date fitted: _______________ Respirator fitted: ______________ If no, appointment: _________________
Revised: April 10, 2013- Brenna Coles