Aquinas Health History Form

AQUINAS HEALTHCARE EMPLOYEE HEALTH HISTORY

Medical History:

(To be completed by the Employee prior to the physical examination. Check all that apply.)

HEPATITIS B VACCINATION ACCEPTANCE/DECLINATION

Hepatitis B is a liver infection caused by the Hepatitis B virus (HBV). Hepatitis B is transmitted when blood, semen, or another body fluid from a person infected with the Hepatitis B virus enters the body of someone who is not infected. This can happen through sexual contact; sharing needles, syringes, or other drug-injection equipment; or from mother to baby at birth. For some people, hepatitis B is an acute, or short-term, illness, but for others, it can become a long-term, chronic infection.

Hepatitis B vaccine is available to employees who could be expected to come into contact with human blood and other potentially infectious materials in the course of their work. The vaccine is usually given as a 3-shot series over a 6-month period. Some people should not get this vaccine:

• • If you have any severe, life-threatening allergies. If you ever had a life-threatening allergic reaction after a dose of hepatitis B vaccine, or have a severe allergy to any part of this vaccine, you may be advised not to get vaccinated. Ask your health care provider if you want information about vaccine components.
• • If you are not feeling well. If you have a mild illness, such as a cold, you can probably get the vaccine today. If you are moderately or severely ill, you should probably wait until you recover. The doctor can advise you.

Please indicate if you would like to have or want to decline the Hepatitis B vaccination by checking the appropriate 1 box below. Please check only 1 box, as the second box would mean you want the shots, so please read carefully.