ANIMAL HANDLER & USERS MEDICAL QUESTIONNAIRE

This CONFIDENTIAL medical history form must be completed on initial enrollment and 
yearly thereafter as part of WPI’s Occupational Health Program.
Please answer all questions completely.  Mail or take this questionnaire (marked Confidential)  to: 
Occupational Health, Fallon Clinic ; 630 Plantation St; Worcester MA 01605; 508-853-2854

Indicate One:              Initial ___           Annual _____

Name_____________________________________ Date of birth ________________

Status:		oFaculty					oStaff    		
		oUndergraduate Student 			oGraduate Student
Phone #:_________________________________  
		
1. In your lab, are you in contact with laboratory or wild animals?  Yes____   No _____
	List what type(s) of animal(s) _________________________________________
	Length of exposure time per day and/or week____________________________

2. Do you work with infectious agents or any other biological hazard? Yes____ No ____
	If “Yes,” list type:___________________________________________________
	How many hours per week do you work with these agents? _________________

3. In the lab, do you work with carcinogens, any other toxic hazardous substances, or animals to which carcinogens or toxic substances have been administered?	                         Yes ______         No ______  If “Yes,” List what type:_______________________
            
 4. Are you required to lift more than 20 pounds on a frequent basis? Yes ___ No ____

5. In the lab, do you wear personal protective equipment?	           Yes ___ No____
    If “Yes,” list what type:___________________________________

6. Do you change or shower before leaving the lab?			   Yes ___ No____
	
7. Have animals in the lab ever bitten you?	                         Yes ___ No____
    If “Yes,” list what animals______________________________________________

8. Do you have any contact with animals outside of the lab? 	   Yes ___No____
    If “Yes,” list what animals______________________________________________
    If “Yes”, how many hours per day on average?_____________________________

9. Do you currently have any of the following symptoms?
    Itchy eyes	Yes___ No___	                Runny nose 	    Yes ___ No____
    Cough	Yes___ No___		         Chest tightness  Yes ___ No____
    Wheeze	Yes___ No___		         Skin rash        Yes ___ No____

10. Do you currently or have you ever smoked?  Yes___ No___  
If “Yes,” for how long? _____ 
How many packs per day do you/have you smoked? ____
When did you quit smoking? ___________

11.  Immunization history					Date Received
	Tetanus						____________
It is highly recommended your immunizations be kept current, especially Tetanus. 

       Rabies							____________
       Hepatitis B series					____________
       BCG							____________
       Tuberculosis PPD	Result + / -			____________ 

12.  Do you have or have you ever had:
	Medication allergy/sensitivity			                 Yes ____ No ____
	List _____________________________________________________________
	Food allergy/sensitivity  					   Yes ____ No ____
	List _____________________________________________________________
	Hay fever					                  Yes ____ No ____
	Asthma					                  Yes ____ No ____
	Insect / Animal / Plant Allergies				   Yes ____ No ____
	List _____________________________________________________________
Skin tests for allergies				                  Yes ___ No ____
	List ____________________________________________________________
	Tuberculosis					                  Yes ___ No ____
	Hepatitis					                  Yes ___ No ____
	List type and for how long regardless if A, B, or C ________________________
	
13. Do you have any chronic illness (e.g., high BP, diabetes)? 	  Yes ____ No_____
	List __________________________________________________________

14. Are you currently taking prescription/over-the-counter medications? Yes___ No____
	List __________________________________________________________

15. Are you pregnant or planning to become pregnant this academic school year?                           
            N/A___ Yes___ No___

16. Do you want to talk to an Occupational Healthcare Specialist?      Yes ___ No ___

Signature___________________________________Date________________________

Return completed form to:		Occupational Health; Fallon Clinic
					630 Plantation Street
					Worcester, MA 01605