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Community Care Physicians

OCCUPATIONAL HEALTH SERVICES 
Rennselaer Technology Park, 101 Jordan Rd., North Greenbush, NY  12180 
(518) 274-9126
Fax (518) 274-9487

Annual Health History
Research Animal Users

If you are associated with the University at Albany and have a NetID, you may log in via the link at the top of this page and submit this form electronically. Your name and email address will then be filled in automatically. If you do not have a NetID, you will need to fill this form out and then print and fax it to the number at the top of the form.

Name:

Examinee Email Address:

Principal Investigator:

Assign:


If Field Studies, please describe:

1. Have you worked with animals before?


If Yes, please specify when, where, and how:

2. Do you have pets?


If Yes, please specify:

3. Do any of your close personal contacts (family, friends, significant others)
work with animals, or do they have pets?


If Yes, please specify:

4. Have you, to your knowledge, ever had an illness as a result of exposure to animals?


If Yes, please specify:

5. Have you had asthma?

5a. Do you take asthma medications?


If Yes, please specify each Medication Name, Dose, and Frequency:


If you are using a "rescue" inhaler, how often have you used it in the last month?

5b. Have you been hospitalized or been seen in the emergency room because of asthma in the last five years?

5c. Have you taken steroids (prednisone) for asthma in the last five years?

6. Have you had any of the following symptoms, not associated with a cold or flu, in the last 5 years?

Watery, Itchy eyes:


Runny, stuffy, nose:


Post-nasal drip:


Sneezing spells:


Frequent dry cough:


Wheezing in chest:


Skin rash:


Hives:


Swelling of the throat:

6a. Do you take medications for any of these symptoms?


If Yes, please specify each Medication Name, Dose, and Frequency:

7. Have you ever been treated by a doctor for allergies?

8. Have you identified what substances of exposures trigger your symptoms?


If Yes, please specify:

9. Do you take other medication?


If Yes, please specify:

10. Do you have other health issues?


If Yes, please specify:

11. When was your last tetanus booster?

Additional comments/information:

12. HIPAA Authorization
I have read and understand the attached HIPAA form and authorize
Community Care Physicians, P.C. to use and/or disclose certain
protected health information (PHI) about me to Dr. Antigone McKenna and
my Principal Investigator.

 

 

Disclaimer

I understand that by submitting this form, the information entered into this form will be transmitted via email over the Internet which may not be secure. If this is unacceptable to me, I can instead print out the form and fax it to the number at the top of the form.

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