This form contains 226 fields organized into 63 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
Abdomen Exam
Abdomen Exam Comment	Text	Provide any additional comments or observations regarding the abdomen exam. Fill only if 'Abdomen Abnormal Status' is 'Yes'. Depends on: Abdomen Abnormal Status
Abdomen Abnormal Status	Text	Indicate if the abdomen exam findings are abnormal.
Abdomen Normal Status	Text	Indicate if the abdomen exam findings are normal.
Alcohol Use
Consumes alcohol occasionally	Checkbox	Check this box if the individual consumes alcohol occasionally.
Denies use	Checkbox	Check this box if the individual denies any alcohol use.
Consumes alcohol on a daily basis	Checkbox	Check this box if the individual consumes alcohol on a daily basis.
Consumes alcohol socially	Checkbox	Check this box if the individual consumes alcohol socially.
Allergies
Other Drug Allergy	Text	Please specify any other drug allergies not listed. Fill only if 'Other/Drug' is 'Yes'. Depends on: Other/Drug
Smoke	Checkbox	Check this box if the person has an allergy or sensitivity to smoke.
Vinyl	Checkbox	Check this box if the person has an allergy to vinyl.
Nitrate	Checkbox	Check this box if the person has an allergy to nitrates.
Other/Drug	Checkbox	Check this box if the person has other allergies not listed or any drug allergies.
Latex	Checkbox	Check this box if the person has an allergy to latex.
Penicillin	Checkbox	Check this box if the person has an allergy to penicillin.
Animal/Pet Dander	Checkbox	Check this box if the person has an allergy to animal or pet dander.
Seasonal	Checkbox	Check this box if the person has seasonal allergies.
Cardiac Exam
Abdomen Exam Comment	Text	Provide any additional comments or observations regarding the abdomen examination. Fill only if 'Cardiac Exam Abnormal' is 'Yes'. Depends on: Cardiac Exam Abnormal
Cardiac Exam Normal	Text	Indicate if the cardiac examination findings were normal.
Cardiac Exam Abnormal	Text	Indicate if the cardiac examination findings were abnormal.
Cardiac Exam Comment	Text	Provide any additional comments or observations regarding the cardiac examination. Fill only if 'Past Medical History: Heart Disease' is 'Yes'. Depends on: Heart Disease
Chest Pain
No	Checkbox	Check this box if the person does not experience chest pain.
Yes	Checkbox	Check this box if the person experiences chest pain.
Chest Pain Details Part 1	Text	Please provide the initial details or onset information regarding any chest pain experienced.
Chest Pain Details Part 2	Text	Please provide additional details or ongoing information about any chest pain experienced.
Clinician Information
Clinician License Number & State	Text	Enter the clinician's professional license number and the state where it was issued.
Clinician Printed Name	Text	Enter the full printed name of the examining clinician.
Clinician Signature	Text	Provide the signature of the examining clinician.
Signature Date	Date	Enter the date the clinician signed this form.
Close Contact with TB Patient
No	Checkbox	Check this box if you have NOT had close contact with someone who has Tuberculosis (TB).
Yes	Checkbox	Check this box if you have had close contact with someone who has Tuberculosis (TB).
Coughing Up Blood
Coughing up blood - No	Checkbox	Check this box if you have not been coughing up blood.
Coughing up blood - Yes	Checkbox	Check this box if you have been coughing up blood.
Employee Information
Employee Name	Text	Please enter the full name of the employee.
Date of Birth	Date	Please provide the employee's date of birth.
Fever, Chills, or Night Sweats
No	Checkbox	Check this box if you have NOT experienced fever, chills, or drenching night sweats for no known reason.
Yes	Checkbox	Check this box if you have experienced fever, chills, or drenching night sweats for no known reason.
First MMR Vaccine Dose
First MMR Vaccine Date	Date	Please provide the date when the first MMR vaccine dose was administered.
First MMR Vaccine Immune Status	Text	Indicate the immune status for the first MMR vaccine dose.
First MMR Vaccine Non-Immune Status	Text	Indicate if the individual is non-immune for the first MMR vaccine dose.
General
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General Appearance Exam
General Appearance Abnormal Findings	Text	Describe any abnormal findings observed during the general appearance examination.
General Appearance Examination Comment	Text	Provide additional comments or context for the general appearance examination findings. Fill only if 'General Appearance Abnormal Findings' is 'Yes'. Depends on: General Appearance Abnormal Findings
General Appearance Normal Findings	Text	Describe the normal findings observed during the general appearance examination.
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Genito-Urinary Exam
Genito-Urinary Comment	Text	Provide any relevant comments or details regarding the Genito-Urinary system examination, including hernias. Fill only if 'Genito-Urinary Abnormal' is 'Yes'. Depends on: Genito-Urinary Abnormal
Genito-Urinary Abnormal	Text	Indicate if the Genito-Urinary system, including hernias, is abnormal during the physical examination.
Genito-Urinary Normal	Text	Indicate if the Genito-Urinary system, including hernias, is normal during the physical examination.
Health Impairment Statement
choicebutton_1_28_474231c3	CheckBox
Health Screen (Medical History)
Medical History Details	Text	Provide any additional details or notes regarding the applicant's medical history or health screen.
HEENT Exam
HEENT Examination Comments	Text	Provide any additional comments for the Head, Eyes, Ears, Nose, and Mouth examination. Fill only if 'HEENT Abnormal Status' is 'Yes'. Depends on: HEENT Abnormal Status
HEENT Abnormal Status	Text	Indicate the abnormal status of the Head, Eyes, Ears, Nose, and Mouth examination.
HEENT Normal Status	Text	Indicate the normal status of the Head, Eyes, Ears, Nose, and Mouth examination.
Hepatitis Type
Hepatitis	Checkbox	Check this box if the individual has a history of Hepatitis.
Hepatitis A	Checkbox	Check this box if the individual has a history of Hepatitis A. Fill only if 'Hepatitis' is 'Yes'. Depends on: Hepatitis
Hepatitis B	Checkbox	Check this box if the individual has a history of Hepatitis B. Fill only if 'Hepatitis' is 'Yes'. Depends on: Hepatitis
History of TB/LTBI
History of TB/LTBI - No	Checkbox	Check this box if you do not have a history of TB, LTBI, and treatment.
History of TB/LTBI - Yes	Checkbox	Check this box if you have a history of TB, LTBI, and treatment.
TB/LTBI Treatment Details	Text	Please provide details regarding your history of TB or LTBI, including any treatment received. Fill only if 'Past Medical History: Tuberculosis' is 'Yes'.
Close Contact Details	Text	Please provide details about your close contact with someone who has TB.
Immunosuppression
No, Current or Planned Immunosuppression	Checkbox	Check this box if you do not currently have and are not planning to have immunosuppression, including human immunodeficiency virus infection, receipt of an organ transplant, treatment with a TNF-alpha antagonist, or chronic steroid use.
Yes, Current or Planned Immunosuppression	Checkbox	Check this box if you currently have or are planning to have immunosuppression, which includes human immunodeficiency virus infection, receipt of an organ transplant, treatment with a TNF-alpha antagonist, or chronic steroid use.
Inability to Work
Not Physically/Mentally Able to Work	Checkbox	Check this box if the individual is not physically or mentally able to work, requiring a reason to be specified.
Reason for Inability to Work	Text	Please provide the reason why the individual is not physically or mentally able to work. Fill only if 'Not Physically/Mentally Able to Work' is 'Yes'. Depends on: Not Physically/Mentally Able to Work
Known Allergic Reactions
Allergic Reactions List	Text	Please provide a comprehensive list of all known allergic reactions the individual has experienced. Fill only if 'Smoke', 'Vinyl', 'Nitrate', 'Other/Drug', 'Latex', 'Penicillin', 'Animal/Pet Dander', 'Seasonal' is 'Yes' for any. Depends on: Seasonal, Nitrate, Penicillin, Animal/Pet Dander, Latex, Smoke, Vinyl, Other/Drug
Lab Report Attachment Instruction
Number of Attached Reports	Number	Provide the total number of lab reports and vaccination records attached to this form.
Length of Tobacco Use
>10 years	Checkbox	Check this box if the individual has used tobacco for a period longer than 10 years. Fill only if 'Smokes >1 pack/day', 'Social Smoker', 'Smoke several cigarettes per day' is 'Yes', any. Depends on: Smokes >1 pack/day, Social Smoker, Smoke several cigarettes per day
6-10 years	Checkbox	Check this box if the individual has used tobacco for a period of 6 to 10 years. Fill only if 'Smokes >1 pack/day', 'Social Smoker', 'Smoke several cigarettes per day' is 'Yes', any. Depends on: Smokes >1 pack/day, Social Smoker, Smoke several cigarettes per day
N/A	Checkbox	Check this box if the individual has not used tobacco for any length of time or if the question is not applicable to them. Fill only if 'Denies present tobacco use' is 'Yes'. Depends on: Denies present tobacco use
1-5 years	Checkbox	Check this box if the individual has used tobacco for a period of 1 to 5 years. Fill only if 'Smokes >1 pack/day', 'Social Smoker', 'Smoke several cigarettes per day' is 'Yes', any. Depends on: Smokes >1 pack/day, Social Smoker, Smoke several cigarettes per day
Medical Conditions Checklist
Sickle Cell Trait or Disease	Checkbox	Check this box if you have a history of Sickle Cell Trait or Disease.
Stroke/CVA/TIA	Checkbox	Check this box if you have a history of Stroke/CVA/TIA.
Neuropathy	Checkbox	Check this box if you have a history of Neuropathy.
Hypothyroid	Checkbox	Check this box if you have a history of Hypothyroid.
Kidney Disease	Checkbox	Check this box if you have a history of Kidney Disease.
Injury: non-work	Checkbox	Check this box if you have a history of a non-work-related Injury.
Asthma	Checkbox	Check this box if you have a history of Asthma.
Cancer	Checkbox	Check this box if you have a history of Cancer.
Anxiety	Checkbox	Check this box if you have a history of Anxiety.
Cataracts	Checkbox	Check this box if you have a history of Cataracts.
COPD or Lung Disease	Checkbox	Check this box if you have a history of COPD or Lung Disease.
Diabetes Type II	Checkbox	Check this box if you have a history of Diabetes Type II.
Injury: work	Checkbox	Check this box if you have a history of a work-related Injury.
Liver Disease	Checkbox	Check this box if you have a history of Liver Disease.
GERD/GI Disorder	Checkbox	Check this box if you have a history of GERD/GI Disorder.
Epilepsy	Checkbox	Check this box if you have a history of Epilepsy.
Diabetes Type I	Checkbox	Check this box if you have a history of Diabetes Type I.
Motor Vehicle Accident	Checkbox	Check this box if you have a history of a Motor Vehicle Accident.
Heart Disease	Checkbox	Check this box if you have a history of Heart Disease.
Anemia	Checkbox	Check this box if you have a history of Anemia.
Musculoskeletal disorder	Checkbox	Check this box if you have a history of a Musculoskeletal disorder.
Glaucoma	Checkbox	Check this box if you have a history of Glaucoma.
Hyperthyroid	Checkbox	Check this box if you have a history of Hyperthyroid.
Neck or lower back pain	Checkbox	Check this box if you have a history of Neck or lower back pain.
Headaches	Checkbox	Check this box if you have a history of Headaches.
High Blood Pressure	Checkbox	Check this box if you have a history of High Blood Pressure.
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Medication List
Medication 6	Text	Enter the name of a medication currently being used or reported. Fill only if 'Use Reported' is 'Yes'. Depends on: Use Reported
Medication 5	Text	Enter the name of a medication currently being used or reported. Fill only if 'Use Reported' is 'Yes'. Depends on: Use Reported
Medication 2	Text	Enter the name of a medication currently being used or reported. Fill only if 'Use Reported' is 'Yes'. Depends on: Use Reported
Medication 1	Text	Enter the name of a medication currently being used or reported. Fill only if 'Use Reported' is 'Yes'. Depends on: Use Reported
Medication 3	Text	Enter the name of a medication currently being used or reported. Fill only if 'Use Reported' is 'Yes'. Depends on: Use Reported
Medication 4	Text	Enter the name of a medication currently being used or reported. Fill only if 'Use Reported' is 'Yes'. Depends on: Use Reported
Number of Medications Reported	Text	Enter the total number of medications currently being used or reported. Fill only if 'Use Reported' is 'Yes'. Depends on: Use Reported
Medication Status
Use Reported	Checkbox	Check this box if the user is currently taking or has reported using medications.
None Reported	Checkbox	Check this box if the user is not currently taking and has not reported using any medications.
Musculoskeletal/Gait Exam
Musculoskeletal/Gait Comment	Text	Provide any additional comments or details regarding the Musculoskeletal/Gait exam. Fill only if 'Musculoskeletal/Gait Abnormal Assessment' is 'Yes'. Depends on: Musculoskeletal/Gait Abnormal Assessment
Musculoskeletal/Gait Abnormal Assessment	Text	Enter the assessment for the Musculoskeletal/Gait exam if found to be abnormal. Fill only if 'Past Medical History: Musculoskeletal disorder' is 'Yes'. Depends on: Musculoskeletal disorder
Musculoskeletal/Gait Normal Assessment	Text	Enter the assessment for the Musculoskeletal/Gait exam if found to be normal.
Narcotic/Stimulant Use
Denies use	Checkbox	Check this box if the individual denies any use of narcotics or stimulants.
Presently using prescribed stimulants	Checkbox	Check this box if the individual is currently using stimulants that have been prescribed by a medical professional. Fill only if 'Use Reported' is 'Yes'.
Presently using prescribed narcotics	Checkbox	Check this box if the individual is currently using narcotics that have been prescribed by a medical professional. Fill only if 'Use Reported' is 'Yes'.
Neck Exam
Neck Exam Further Details	Text	Enter any further details or findings related to the neck examination that do not fit into the other fields. Fill only if 'Neck Exam Comment' is 'Yes'. Depends on: Neck Exam Comment
Neck Exam Comment	Text	Provide any additional comments or detailed observations regarding the neck examination. Fill only if 'Past Medical History: Neck or lower back pain' is 'Yes'. Depends on: Neck or lower back pain
Neck Abnormal Status	Text	Indicate the abnormal status of the neck during the physical examination, such as 'AB' for abnormal.
Neck Normal Status	Text	Indicate the normal status of the neck during the physical examination, such as 'NL' for normal.
Neurologic Exam
Neurologic Exam Comment	Text	Provide any additional comments or details regarding the Neurologic Exam. Fill only if 'Neurologic Exam Abnormal Status' is 'Yes'. Depends on: Neurologic Exam Abnormal Status
Neurologic Exam Abnormal Status	Text	Enter the abnormal status for the Neurologic Exam.
Neurologic Exam Normal Status	Text	Enter the normal status for the Neurologic Exam.
Other Body Systems Exam
Other Body systems	Checkbox	Check this box if there are abnormal findings related to other body systems not specifically listed in the physical exam.
Other Body Systems Abnormal	Text	Enter any observations related to abnormal findings for other body systems. Fill only if 'Past Medical History: Other' is 'Yes'. Depends on: Other
Other Body Systems Comment	Text	Provide any additional comments or details regarding the examination of other body systems. Fill only if 'Other Body Systems Abnormal' is 'Yes'. Depends on: Other Body Systems Abnormal
Other Body Systems Normal	Text	Enter any observations related to the normal findings for other body systems.
Other Medical Condition
Other Medical Condition 3	Text	Please provide details for the third other medical condition not listed. Fill only if 'Other' is 'Yes'. Depends on: Other
Other Medical Condition 1	Text	Please provide details for the first other medical condition not listed. Fill only if 'Other' is 'Yes'. Depends on: Other
Other Medical Condition 2	Text	Please provide details for the second other medical condition not listed. Fill only if 'Other' is 'Yes'. Depends on: Other
Other	Checkbox	Check this box if you have a medical condition that is not listed in the provided options and specify it in the adjacent text field.
Other Surgical Notes
Other Surgical Notes	Text	Please provide any additional notes regarding past surgeries not listed above. Fill only if 'None Reported' is 'No'. Depends on: None Reported
Page 1
Employee Name	Text	Please provide the full name of the employee.
Date of Birth	Date	Please enter the employee's date of birth.
Past Medical History Comments
Past Medical History Comments	Text	Please provide any additional comments or details regarding the past medical history not covered by the listed conditions. Fill only if 'choicebutton_0_99_bc360a38' is 'Yes'. Depends on: choicebutton_0_99_bc360a38
Past Medical History Reporting Status
Other Past Medical History	Text	Please provide any past medical history not listed in the available options.
None Reported	Checkbox	Check this box if you have no past medical history to report.
Past Medical Illness
Other Past Medical Illnesses (Line 1)	Text	Please provide any other past medical illnesses not explicitly listed in the options above.
Other Past Medical Illnesses (Line 2)	Text	Please provide any additional past medical illnesses not explicitly listed in the options above. Fill only if 'Tuberculosis' is 'Yes'. Depends on: Tuberculosis
Mumps	Checkbox	Check this box if you have had Mumps in the past.
Measles	Checkbox	Check this box if you have had Measles in the past.
Tuberculosis	Checkbox	Check this box if you have had Tuberculosis in the past.
Rubella	Checkbox	Check this box if you have had Rubella in the past.
None Reported	Checkbox	Check this box if you have not had any of the listed medical illnesses in the past.
Varicella (Chicken Pox)	Checkbox	Check this box if you have had Varicella (Chicken Pox) in the past.
Past Surgical History
Thyroidectomy	Checkbox	Check this box if the individual has had a thyroidectomy. Fill only if 'None Reported' is 'No'. Depends on: None Reported
Tubal Ligation	Checkbox	Check this box if the individual has had a tubal ligation. Fill only if 'None Reported' is 'No'. Depends on: None Reported
Tonsillectomy	Checkbox	Check this box if the individual has had a tonsillectomy. Fill only if 'None Reported' is 'No'. Depends on: None Reported
Salpingectomy	Checkbox	Check this box if the individual has had a salpingectomy. Fill only if 'None Reported' is 'No'. Depends on: None Reported
Mastectomy	Checkbox	Check this box if the individual has had a mastectomy. Fill only if 'None Reported' is 'No'. Depends on: None Reported
Lumpectomy	Checkbox	Check this box if the individual has had a lumpectomy. Fill only if 'None Reported' is 'No'. Depends on: None Reported
Ovarian cystectomy	Checkbox	Check this box if the individual has had an ovarian cystectomy. Fill only if 'None Reported' is 'No'. Depends on: None Reported
Breast reduction	Checkbox	Check this box if the individual has had a breast reduction. Fill only if 'None Reported' is 'No'. Depends on: None Reported
Hysterectomy	Checkbox	Check this box if the individual has had a hysterectomy. Fill only if 'None Reported' is 'No'. Depends on: None Reported
Cataract removal	Checkbox	Check this box if the individual has had cataract removal surgery. Fill only if 'None Reported' is 'No'. Depends on: None Reported
Laminectomy	Checkbox	Check this box if the individual has had a laminectomy. Fill only if 'None Reported' is 'No'. Depends on: None Reported
Liposuction	Checkbox	Check this box if the individual has had liposuction. Fill only if 'None Reported' is 'No'. Depends on: None Reported
Appendectomy	Checkbox	Check this box if the individual has had an appendectomy. Fill only if 'None Reported' is 'No'. Depends on: None Reported
Hemorrhoidectomy	Checkbox	Check this box if the individual has had a hemorrhoidectomy. Fill only if 'None Reported' is 'No'. Depends on: None Reported
None Reported	Checkbox	Check this box if the individual has no past surgical history to report.
C-Section	Checkbox	Check this box if the individual has had a C-Section. Fill only if 'None Reported' is 'No'. Depends on: None Reported
Cholecystectomy	Checkbox	Check this box if the individual has had a cholecystectomy. Fill only if 'None Reported' is 'No'. Depends on: None Reported
Past Surgical History Report
Other Past Surgical History	Text	Provide details for any past surgical history not listed in the options provided. Fill only if 'None Reported' is 'No'. Depends on: None Reported
Persistent Shortness of Breath
Persistent Shortness of Breath - No	Checkbox	Check this box if you have not experienced persistent shortness of breath.
Persistent Shortness of Breath - Yes	Checkbox	Check this box if you have experienced persistent shortness of breath.
Physical Exam Detail
Respiration Rate	Number	Enter the patient's respiration rate.
Physical Exam Section Header
Overall Abnormal Findings Summary	Text	Please provide a summary or any general comments regarding the overall abnormal physical exam findings.
Overall Normal Findings Summary	Text	Please provide a summary or any general comments regarding the overall normal physical exam findings.
Positive Tuberculosis Test Follow-up
Chest X-ray Date for Positive TB	Date	Please provide the date when the chest X-ray was performed as a follow-up for a positive PPD or QFT test. Fill only if 'PPD (Step 1) - Positive', 'Positive', 'PPD (Step 2) Positive' is 'Yes', any. Depends on: PPD (Step 1) - Positive, Positive, PPD (Step 2) Positive
Chest X-ray Report Reference	Text	Please enter any relevant reference or details for the attached chest X-ray report. Fill only if 'PPD (Step 1) - Positive', 'Positive', 'PPD (Step 2) Positive' is 'Yes', any. Depends on: PPD (Step 1) - Positive, Positive, PPD (Step 2) Positive
PPD/QFT Positive Result Date	Date	Please provide the date when the PPD or QFT test resulted as positive. Fill only if 'PPD (Step 1) - Positive', 'Positive', 'PPD (Step 2) Positive' is 'Yes', any. Depends on: PPD (Step 1) - Positive, Positive, PPD (Step 2) Positive
PPD (Step 1)
PPD (Step 1) - Negative	Checkbox	Check this box if the PPD (Step 1) test result is negative.
PPD (Step 1) - Positive	Checkbox	Check this box if the PPD (Step 1) test result is positive.
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PPD Step 1 Date	Date	Enter the date the PPD Step 1 test was performed.
PPD Step 1 Result	Number	Enter the result or reading for the PPD Step 1 test.
PPD (Step 2)
PPD (Step 2) Positive	Checkbox	Check this box if the PPD (Step 2) test result is positive.
PPD (Step 2) Negative	Checkbox	Check this box if the PPD (Step 2) test result is negative.
PPD Step 2 Date	Date	Enter the date the PPD Step 2 test was administered or resulted.
PPD Step 2 Result	Text	Provide the result or reading for the PPD Step 2 test.
Prior TB Test Documentation
Prior TB Test Documentation No	Checkbox	Check this box if you do not have documentation of prior TB tests, either a tuberculin skin test (TST) or an interferon-gamma release assay (IGRA) blood test and results.
Prior TB Test Documentation Yes	Checkbox	Check this box if you have documentation of prior TB tests, either a tuberculin skin test (TST) or an interferon-gamma release assay (IGRA) blood test and results.
Productive Cough
Productive Cough No	Checkbox	Check this box if you have NOT had a productive cough for more than 3 weeks.
Productive Cough Yes	Checkbox	Check this box if you have had a productive cough for more than 3 weeks.
Psychiatric Exam
Psychiatric Comments	Text	Provide any additional comments or details regarding the psychiatric examination. Fill only if 'Psychiatric Abnormal Findings' is 'Yes'. Depends on: Psychiatric Abnormal Findings
Psychiatric Abnormal Findings	Text	Enter any abnormal psychiatric findings or observations. Fill only if 'Past Medical History: Anxiety' is 'Yes'. Depends on: Anxiety
Psychiatric Normal Findings	Text	Enter any normal psychiatric findings or observations.
Quantiferon Test (QFT)
Negative	Checkbox	Check this box if the Quantiferon Test result is negative.
Positive	Checkbox	Check this box if the Quantiferon Test result is positive.
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Quantiferon Test Date	Date	Enter the date the Quantiferon Test (QFT) was performed.
Residence in High TB Rate Country
No	Checkbox	Check this box if you do not have temporary or permanent residence (for more than 1 month) in a country with a high TB rate, excluding Australia, Canada, New Zealand, the United States, and Western or Northern Europe.
Yes	Checkbox	Check this box if you have temporary or permanent residence (for more than 1 month) in a country with a high TB rate, excluding Australia, Canada, New Zealand, the United States, and Western or Northern Europe.
Respiratory Exam
Respiratory System Comments	Text	Provide any additional comments or observations regarding the respiratory system examination. Fill only if 'Respiratory Abnormal Indicator' is 'Yes'. Depends on: Respiratory Abnormal Indicator
Respiratory Abnormal Indicator	Text	Enter any relevant details if the respiratory system examination results were abnormal. Fill only if 'Past Medical History: COPD or Lung Disease' is 'Yes'. Depends on: COPD or Lung Disease
Respiratory Normal Indicator	Text	Enter any relevant details if the respiratory system examination results were normal.
Rubella Test/Vaccination
Rubella Immune	Checkbox	Check this box if the Rubella test or vaccination results indicate the individual is immune.
Rubella Non-Immune	Checkbox	Check this box if the Rubella test or vaccination results indicate the individual is not immune.
Rubella Date	Date	Provide the date the Rubella test was performed or the Rubella vaccination was administered.
Rubella Test/Vaccination Details	Text	Provide any additional details or specific information regarding the Rubella test or vaccination.
Rubeola (Measles) Test/Vaccination
Non-Immune	Checkbox	Check this box if the individual is not immune to Rubeola (Measles).
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Rubeola Test Date	Date	Please provide the date when the Rubeola (Measles) test was performed.
Second MMR Vaccine Dose
Second MMR Vaccine Dose Date	Date	Please provide the date of the second MMR vaccine dose.
Second MMR Vaccine Dose Non-Immune Status	Text	Indicate if the patient is non-immune after the second MMR vaccine dose.
Second MMR Vaccine Dose Immune Status	Text	Indicate if the patient is immune after the second MMR vaccine dose.
Skin Exam
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Skin Exam Comment	Text	Provide any additional comments or details regarding the skin examination.
Skin Exam Abnormal	Text	Enter the finding if the skin examination is abnormal.
Skin Exam Normal	Text	Enter the finding if the skin examination is normal.
Test/Vaccination Table Headers
Diagnostic Tests Section Header	Text	Provide the overall label for the section of the table that details diagnostic tests and their outcomes.
Test/Vaccination Name Column Label	Text	Provide the label for the column that lists specific vaccination types and initial tests.
Administration Date Column Label	Text	Provide the label for the column indicating the date a vaccination or initial test was administered.
Immunity Status Column Label	Text	Provide the label for the column indicating the individual's immunity status for the listed vaccinations or tests.
Tobacco Use
Smokes >1 pack/day	Checkbox	Check this box if the individual smokes more than one pack of cigarettes per day.
Social Smoker	Checkbox	Check this box if the individual identifies as a social smoker.
Smoke several cigarettes per day	Checkbox	Check this box if the individual smokes several cigarettes per day.
Denies present tobacco use	Checkbox	Check this box if the individual currently denies using any tobacco products.
choicebutton_0_102_1f55a12d	CheckBox
Tuberculosis Test Date Header
Quantiferon Test Date	Date	Please enter the date the Quantiferon Test (QFT) was performed.
Unexplained Fatigue
No, Unexplained Fatigue	Checkbox	Check this box if the individual has NOT experienced unexplained fatigue for more than 3 weeks.
Yes, Unexplained Fatigue	Checkbox	Check this box if the individual has experienced unexplained fatigue for more than 3 weeks.
Unexplained Weight Loss
No	Checkbox	Check this box if the individual has not experienced unexplained weight loss.
Yes	Checkbox	Check this box if the individual has experienced unexplained weight loss.
Vitals
Pulse	Number	Enter the patient's pulse rate.
Respiratory Rate	Number	Enter the patient's respiratory rate.
Blood Pressure	Text	Enter the patient's blood pressure reading.
Work Limitations
Able to Work with Limitations	Checkbox	Check this box if the individual is able to work, but with specific limitations that need to be documented.
textbox_1_92_4d879485	Text	Depends on: Able to Work with Limitations

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