Champlain Medical

Fields with * are required.

Company

Company Name (if not selected above) *

First Name *

Last Name *

Birth Date *

Email *

Exposure to Animals

Does this position require contact with animals? *

Yes No

If yes, please identify type (check all that apply)

Rodents

Small Animals

Pigs

Fish, frogs and aquatics

Other

Allergy and Respiratory System Health History

Asthma or other chronic respiratory disease *

Yes No

Allergic skin reactions such as hives, rash or itching? *

Yes No

Please Explain

Skin conditions such as eczema, psoriasis, dermatitis *

Yes No

Known or suspected animal allergies. Please check off any animal reaction(s):

Runny/stuffy nose

Sneezing

Coughing

Wheezing

Chest Tightness

Short of Breath

Hives

Skin Rash

Throat Swell

Known or suspected allergies to chemicals, latex, food or environment: *

Yes No

Explain

Immune/Metabolic System Health History - check all that apply

Chronic health conditions such as diabetes

Valvular Heart Disease

Reproductive health counseling available - Would you like to speak with an occupational health provider?

Kidney or liver disease

History of spleen problems or absence of spleen

Immunize system deficiencies or limitations to your ability to fight off disease or infection

Do you have any questions concerning your health as it relates to the workplace that you would like to discuss an occupational health professional?

General Health and Immunizations:

Is your tetanus immunization up to date (within 10 years) *

Yes No

Has your health changed in any way over the last year? *

Yes No

If yes please explain

Respirator:

Are you currently using respiratory protection or an N95 mask? *

Yes No

Animal Handler Form