Healthcare Food Handlers Medicals

Healthcare Food Handlers Medicals

Patient Information

Patient Name:

Employment Information

Start Date of Employment:

Emergency Contact

Medical History & Current Status

Current Medications:

Communicable Disease Screening (required for food handlers)

Within the past 14 days, have you experienced any of the following? Check all that apply and provide onset dates where applicable.

Immunizations & Laboratory

Hepatitis A vaccination status:

Vaccinated — doses given: Dates:

Immune (documented positive anti-HAV titer). Date:

Stool specimen required: If required, specimen collected:

Provider Assessment (to be completed by examining clinician)

Fit for duty with no restrictions

Fit for duty with restrictions — specify:

Excluded from food handling until cleared by clinician or public health authority. Recommended clearance criteria:

Authorization, Consent & Privacy Acknowledgment

By signing below I certify that the information I have provided on this form is true and complete to the best of my knowledge. I consent to the medical examination, diagnostic testing, and treatment related to food handler clearance that are necessary to evaluate my fitness for food handling duties.

I authorize the release of medical information related to this examination, including test results and diagnosis, to my employer or their designated representative for the sole purpose of determining work restrictions, return-to-work status, and compliance with public health requirements. This authorization is limited to information reasonably necessary for those purposes.

I understand that the information released under this authorization remains protected health information and will be handled in accordance with applicable privacy laws. I may revoke this authorization in writing at any time, except to the extent action has already been taken in reliance upon it. This authorization expires on:

I acknowledge receipt of the facility's privacy practices and understand my rights regarding the handling of my health information.

I acknowledge receipt of the privacy notice and consent to release limited information as described above.

Patient Certification

I affirm that I have read and understand the statements above, that I have been given an opportunity to ask questions, and that the answers contained herein are accurate and complete. I understand that falsifying information related to communicable disease may result in exclusion from work and other consequences under employer or public health policies.

Sign Now