ACS Annual Health Assessment/TB Screening Form Please enable JavaScript in your browser to complete this form.ACS HOME CARE LLC – ANNUAL HEALTH ASSESSMENT / TB SCREENEmployee's name *FirstLastDate of birth *Have you experienced any of the following medical problems WITHIN THE PAST YEAR?Disabling Injury *NoYesHypertension *NoYesHernia *NoYesFainting *NoYesHeart Condition *NoYesWeight Change *NoYesAsthma *NoYesArthritis *NoYesMental Illness *NoYesInfections *NoYesAllergies *NoYesDiabetes *NoYesSinus Problems *NoYesSkin Disease/Rash *NoYesSeizures *NoYesAnemia *NoYesBack Problems *NoYesStomach Problems *NoYesSurgery *NoYesFracture *NoYesHave you consulted your physician for this/these problem(s)? *NoYesNot applicableIf Yes, please tell us the problem and the outcome to the problem below:Problem 1:Outcome of Problem 1:Problem 2:Outcome of Problem 2:Problem 3:Outcome of Problem 3:Problem 4:Outcome of Problem 4:Please list all medications you are currently taking (If none, enter "none"): *Do you have any allergies? *NoYesIf Yes, please list all your allergies below:Do you currently have any of the following symptoms?Night Sweats *NoYesChronic/Persistent Cough *NoYesWeight Loss *NoYesFatigue *NoYesFlu-like Symptoms *NoYesLow grade fever *NoYesChills *NoYesLack of Appetite *NoYesBlood color sputum *NoYesWeakness *NoYesDiabetes *NoYesChest Pain *NoYesHave you been exposed to anyone exhibiting the above signs and symptoms, or someone who has had active tuberculosis within the past year? *NoYesThis is to certify, that to the best of my knowledge, there are no health impairments present that are of potential risk to me, patients, or other employees, including the habituation or addiction to depressants, stimulants, narcotics, alcohol or other drugs or substances, which may impair my performance. I understand that any falsification or misrepresentation of my past medical history is grounds for termination of my employment. I also understand that this Health Assessment and TB Screen does not replace medical care and/or advice that I should seek from a physician. *Clear SignatureEmployee's SignatureDate *Thank you for completing this form. PLEASE SCROLL DOWN THIS PAGE AND CLICK "SUBMIT"The information directly below, between the lines, is FOR OFFICE USE ONLY. Please scroll down PAST the FOR OFFICE USE ONLY section and "SUBMIT" this form.______________________________-= FOR OFFICE USE ONLY =-Examiner, based on the review of the information provided by this employee, and this screening assessment:Does this employee appear to be free of any symptoms of infectious disease?NO | YESDoes this employee appear to be free of potential risk to themselves, patients, or other employees?NO | YESIs the employee free of any functional limitation?NO | YESDoes this employee appear to be able to continue to safely work?NO | YES If No was answered to any of the above questions, explain why and the recommended actions for the employee to take: Examiners Printed Name and Title: Examiners Signature: Date of verbal review with the above employee: ______________________________Submit