Annual Employee Health Review

The Hawaii Department of Health requires a yearly health screening.  Please complete and submit your responses.

Name:

Employee Number:

Department:

Job Title:

Screening Questions

Over the past year have you had any health conditions develop which may impair/impact your ability to safely provide patient care and/or safely perform the functions of your job?

Please select... No Yes

If yes, please specify:

Have you had any infections or communicable disease since your last health review?

Please select... No Yes

If yes, please specify:

Please review the list of symptoms below and check the appropriate box stating whether you DO or DO NOT have that symptom:

Productive cough (3 weeks or more)

Yes

No

Persistent weight loss without dieting

Yes

No

Persistent low-grade fever

Yes

No

Night sweats

Yes

No

Loss of appetite

Yes

No

Swollen glands, usually in neck

Yes

No

Recurrent kidney or bladder infection

Yes

No

Coughing up blood

Yes

No