ETA 9216 Health History Form

U.S. Department of Labor Employment and Training Administration Office of Job Corps

ETA FORM 9216 OMB Control No. 1205-0219 Expiration Date: 05/31/2025

Health History Form

Instructions: Welcome to Job Corps Health and Wellness. We know you provided some health information before arriving and now that you are here, we want to make sure we understand your health so we can meet your needs. Some of the questions may seem similar. Your answers on this form will help Job Corps’ healthcare providers get an accurate history of your medical concerns and conditions. These questions will help us get to know you better. This information is confidential. Please fill in all pages.

Part 1: Medical History
Conditions
Have you ever had any of the following conditions: (check all that apply)
☐ ADHD/ADD	☐ Headache/migraine	☐ Kidney/urine problem	☐ Sports injury
☐ Anemia/blood disorder	☐ Head injury/concussion	☐ Mental health issues	☐ Stomach/bowel problem
☐ Asthma	☐ Hearing loss	☐ Mononucleosis	☐ Substance use issues
☐ Back problem/scoliosis	☐ Heart disease/murmur	☐ Mouth or teeth issues	☐ Thyroid disorder
☐ Broken bone	☐ Hepatitis/liver disease	☐ Seizures/epilepsy	☐ Tuberculosis
☐ Cancer	☐ High blood pressure	☐ Skin disorder	☐ Vision problems
☐ Diabetes	☐ Joint pain/swelling	☐ Sleep problems	☐ Weight issues
Describe any other health problems that we should know about.
List any health problems or diseases that run in your family.

Allergies
Do you have allergies to any of the following? (check all that apply)
☐ Food	☐ Medicine or drugs	☐ Pollen/grass/season allergies	☐ Animals
☐ Latex	☐ Metals	☐ Milk/Lactose
☐ Other (Specify)
If you have an allergy, tell us more about it. What triggers the allergy? What happens if you’re exposed?

Medications

5. List all prescription and non-prescription medications, vitamins, supplements, home remedies, birth control, herbs, inhalers, or other medications that help with your mood or behavior (attach extra pages if needed).

Medication	Dose (e.g., mg/pill)	How many times per day?	Reason
Have you stopped taking any medications in the past 3 months?		☐ Yes	☐ No
Did you bring any medications with you?		☐ Yes	☐ No

Surgical and Hospitalization History
Have you ever been in the hospital overnight?	☐ Yes	☐ No
Have you ever had surgery?	☐ Yes	☐ No

Part 2: Health Behaviors
Health Behaviors, Unhealthy Behaviors, and Safety Issues
How would you rate your sleep?	☐ Excellent	☐ Good	☐ Fair	☐ Poor
How would you rate your healthy eating habits?	☐ Excellent	☐ Good	☐ Fair	☐ Poor
Have you been trying to gain or lose weight?			☐ Yes	☐ No
Do you drink soda, pop, or sports drinks daily?			☐ Yes	☐ No
Do you brush your teeth at least twice a day?			☐ Yes	☐ No
Do you floss your teeth at least once a day?			☐ Yes	☐ No
When playing sports, do you wear a mouthguard?			☐ Yes	☐ No
Have you seen a dentist in the last 12 months or sooner?			☐ Yes	☐ No
Do you always wear a seatbelt when in a car?			☐ Yes	☐ No
Do you have access to guns when at home? If yes, are they kept in a lock box?			☐ Yes ☐ Yes	☐ No ☐ No
Do you ever carry weapons?			☐ Yes	☐ No
Has anyone ever touched you physically or sexually when you didn’t want them to?			☐ Yes	☐ No
Has a close friend or partner ever hit, punched, or kicked you?			☐ Yes	☐ No
Have you ever vaped, smoked, or used nicotine products?			☐ Yes	☐ No
Do you use alcohol?			☐ Yes	☐ No
Do you use drugs?			☐ Yes	☐ No

Sexual History
Have you ever had sex? (Skip to 31 if the answer is “no”.)				☐ Yes		☐ No
Are you currently involved in a sexual relationship?				☐ Yes		☐ No
What best describes your past sexual partners?			☐ Male	☐ Female		☐ N/A
How often do you use condoms when you have sex?	☐ Never	☐ Sometimes		☐ Always		☐ N/A
Have you ever had a sexually transmitted infection or disease (e.g., Chlamydia, gonorrhea)?				☐ Yes		☐ No
Do you use any of the following? (check all that apply) ☐ None ☐ Birth control pills ☐ Depo Provera ☐ Ring ☐ IUD ☐ Nexplanon ☐ Condoms ☐ Pull out/withdrawal ☐ Patch ☐ Other:
Would you like to discuss or receive birth control?					☐ Yes	☐ No

Reproductive Health History
Have you ever been pregnant or gotten someone else pregnant?					☐ Yes	☐ No
If yes:	Total number of pregnancies:	Number of births:
For females with periods:
Date (month/day) of last menstrual period:
How would you describe your period?			☐ Heavy	☐ Medium	☐ Light
How many days does your period last?
Do you get cramps or experience pain during your period?					☐ Yes	☐ No

Part 3: Sports Clearance
36. What types of sports or exercise do you enjoy?
Has a doctor ever denied or restricted your participation in sports?	☐ Yes	☐ No
Have you ever passed out, or nearly passed out during or after exercise?	☐ Yes	☐ No
Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?	☐ Yes	☐ No
Does your heart ever race or skip beats (irregular beats) during exercise?	☐ Yes	☐ No
Has your doctor ever told you that you have any heart problems (such as high blood pressure, high cholesterol, or a heart murmur)?	☐ Yes	☐ No
Has a doctor ever ordered a test for your heart (i.e., EKG or echocardiogram)?	☐ Yes	☐ No
Do you get lightheaded or feel shorter of breath than expected during exercise?	☐ Yes	☐ No
Do you get tired or short of breath more quickly than friends during exercise?	☐ Yes	☐ No
Are you aware of anyone in your family dying for no apparent reason?	☐ Yes	☐ No
Are you aware of anyone in your family with heart problems or of sudden death before age 50?	☐ Yes	☐ No

Part 4: Pressing Needs
Have you had the following in the past 2 weeks? (check all that apply) ☐ Fever ☐ Rash ☐ Severe pain ☐ Cough ☐ Daily alcohol or drug use ☐ Severe dental pain ☐ Swelling in the mouth, cheek, jaw, or neck
Have you ever had the following? (circle all that apply) ☐ Thoughts of suicide ☐ Suicide attempt ☐ Hurting yourself by cutting, burning, or some other way ☐ Feeling like you may hurt someone else
Do you need to speak with a member of our health and wellness staff urgently?	☐ Yes	☐ No	☐ Not sure
If yes, who do you think could best help you? (check all that apply) ☐ Physician ☐ Nurse ☐ Mental Health ☐ Dentist ☐ Substance abuse counselor

Depression (circle the box that applies)
Over the past two weeks, how often have you been bothered by the following problems?	Not at all	Several days	More than half of the days	Nearly every Day
Little interest or pleasure in doing things	0	1	2	3
Feeling down, depressed, or hopeless	0	1	2	3

I, the undersigned, certify that all information on this form is accurate.
SIGNATURE:	DATE:

For Health and Wellness Center use only.
Nurse notes: Address any affirmative responses by number. Action items.
Referral to the following:
☐ Physician Referral	☐ Mental Health Referral	☐ Dentist Referral	☐ TEAP Referral	☐ Heals Referral

Nurse who reviewed above with student: I, the undersigned, certify that all information on this form is accurate.
SIGNATURE:		DATE:
Practitioner: Address any affirmative responses by number.
Document educational counseling provided and f/u plan:
Practitioner: I, the undersigned, certify that all information on this form is accurate.
SIGNATURE:	DATE:

Paperwork Reduction Act Public Burden Statement: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. Respondents' obligation to complete this form is required to obtain or retain benefits (P.L. 113-128). Public reporting burden is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of Information. Send comments regarding this burden estimate to the U.S. Department of Labor, Division of Adult Services, Room S-4209, Washington, D.C. 20210 (Paperwork Reduction Project 1205-0219). Please do not submit completed forms to this address.

Student name: Center:

DOB: Sex (M/F):

ID #: Race/ethnicity: