HomeMy WebLinkAboutYakima Valley Memorial Hospital - Occupational Health Services Yakima Valley Memorial Hospital
Occupational Health Services Y
1020 South 40 Ave R EC EI V ED MAR 1 2004
Yakima WA 98908
966 -7300
AGREEMENT FOR SERVICES
The following points of agreement shall exist between Yakima Valley Memorial Hospital, represented by
Occupational Health Services "YVMH" herein) and the City of Yakima:
1. YVMH Occupational Health Services agrees to provide Wellness Screenings and subsequent dialogistic
testing as indicated or as requested. Services provided will be performed at the rates summarized below:
Initial Screening: $ 5.00
PSA: $ 24.60
Cholesterol Screening: $ 28.50
Glucose: $ 28.50
Onsite Nursing Fee: $45.00 / Hr./ Nurse
2. Lab Draws shall be scheduled in a manner mutually agreeable for YVMH and Company.
3. YVMH agrees to provide such services in a professional and ethical manner and to the best of its ability.
Occupational Health will share the results with the individual employee and provide a statistical analysis to
the employer while maintaining the integrity of medical confidentiality. As a result of this testing, it will be
the employee's responsibility to seek medical attention from their primary care physician for any further
treatment.
4. As additional consideration for the services to be provided by YVMH, Company agrees to defend at its
expense YVMH against any demand, claim, arbitration, suit, or any other form of legal action for damages
against YVMH arising from services provided by YVMH pursuant to this Agreement, and Company
further agrees to indemnify against any loss, claim, settlement, arbitration or other award, or judgment
arising from said services, and to hold YVMH completely harmless therefrom. This paragraph shall not
apply in the event of negligence on the part of YVMH, its employees or agents
Signed this 30/4 day of / J , 2004
By _- By A Lā
(Signature) Russell M. er
Chief Oper. ng Officer
Yakima Valley Memorial Hospital
c-K A. 1 <,, S
(Print or type name)
x/--
CITY CONTRACT N0.
3
RESOLUTION N0:
MEMORIAL HOSPITAL
YAKIMA VALLEY MEMORIAL HOSPITAL
Occupational Health Services
City of Yakima
Wellness Screening
Initial Screening ā Fee $5.00 / ea.
Includes: MD Established Parameters
Nurses Review of Results
Individual Recommendations to Employees (with further instructions)
Statistical Summary to Employer
On -site Nursing / Lab Services ā Fee $45 / Hour / Medical Staff
Lab Fees: PSA- $24.60 / ea.
Glucose - $28.50 / ea.
Cholesterol Screen - $28.50 / ea.
(Osteoporosis exam will be referred to Medical Associates of Yakima's
Bone Densitometry Department)
Individual follow -up report and employer aggregate reports are provided which give the
employee and the employer the information needed to set wellness goals.
OCCUPATIONAL HEALTH SERVICES
CITY OF YAKIMA
Health Screening Questionnaire
This is a series of questions to help in directing further testing. After this is completed, it will be
reviewed. You will receive the recommendations for the on -site testing that will be scheduled.
** At no time will your personal information be shared with anyone without your specific written
permission. **
Name:
Date of Birth:
Physician: Last Visit:
Gender: Male Female
Marital Status: Single Married Divorced Separated
Ethnicity: Optional, but this information is necessary in assessing health risk.
Caucasian AfricanAmerican Hispanic Asian Native American
GENERAL HEALTH
Tobacco(includes any form):
Usage: Yes No Quit
If Yes or Quit: Smoke Chew Snuff
Years of use
Alcohol: Daily Weekly Special Occasion Never
Medical Conditions (Is your Doctor following your health on a regular basis ?)
Medications: Prescribed: Over the Counter(include vitamins, supplements)
Immunizations: Up -to -Date Unsure Need some Decline
Exercise: Regular Sometimes Rarely Never
Seatbelt Use: Always Sometimes Never
Last Dental Exam:
FAMILY HISTORY (Does any family member have these conditions ?)
High Cholesterol: No Yes Who?
High Blood Pressure: No Yes Who?
Diabetes: No Yes Who?
Stroke: No Yes Who?
Heart Attack: No Yes Who?
Lung Disease: No Yes Who?
Osteoporosis: No Yes Who?
Cancer: No Yes What?
Thyroid: No Yes Who?
Other: No Yes Who?
BASIC HEALTH DATA (Give your best estimate)
Height:
Weight:
Describe yourself: Slender Just right Overweight
Continue on the Next Page
HEALTH QUESTIONNAIRE These are some specific questions about you for this screening.
DIABETES
Extreme Thirst (ongoing) No Yes
Extreme Hunger (ongoing) No Yes
Frequent Urination No Yes
Poor Skin Healing No Yes
Easy Bruising No Yes
Unexplained Weight Loss No Yes
Vision Changes No Yes
Unexplained Fatigue No Yes
Tingling in Hands or Feet No Yes
Frequent Bladder Infections No Yes
Thrush (Oral Infection) No Yes
Ladies:
Yeast Infections No Yes
Diabetes during Pregnancy No Yes
Baby more than 9 Pounds No Yes
CHOLESTEROL
High Blood Pressure: No Yes
Heart Attack: No Yes
Stroke: No Yes
Have you ever been tested? No Yes
Diabetes: No Yes
Thyroid Disease: No Yes
OSTEOPOROSIS
Smoking History: No Yes
Rheumatoid Arthritis: No Yes
Thyroid Disease: No Yes
History of Steroid Medication: No Yes
Fractured Hip: No Yes
Unexplained Fractures: No Yes
If Yes: What bone? Your Age Then:
Ladies:
Hormone Replacement: No Yes
Age of Menopause:
PROSTATE CANCER
Difficulty Urinating: No Yes
Less Force of Urine Stream: No Yes
Dribbling after Urinating: No Yes
Frequent Urination: No Yes
Blood or Pus in Urine: No Yes
Painful Urination: No Yes
Pain with Ejaculation: No Yes
Unexplained Back or Hip Pain: No Yes
OCCUPATIONAL HEALTH SERVICES
Dear Employee,
Thank you for your recent participation in completion of the Health Screening Questionnaire.
Your results have been reviewed and the following recommendations are made.
On -site testing and consultation with a Registered Nurse will be held on
at
Please visit for:
Blood Pressure and Vital Signs
Body Mass Index
Blood Test for Glucose Remember no eating /drinking (water ok) after midnight
Blood Test for Cholesterol Remember no eating /drinking (water ok) after midnight
Blood Test for Prostate Cancer
Consultation regarding Osteoporosis
You will be notified of the results 7 -10 days after this is done.
Judith B. Page, DO
Medical Director
OCCUPATIONAL HEALTH SERVICES
Dear Employee,
The results of the on -site evaluation have been completed. Here is the recommendation for follow -up:
See your physician in the next month for follow -up of
See your physician in the next 3 months for follow -up of
See your physician in the next 6 months for follow -up of
See your physician for your annual check -up.
Enclosed is information that may improve your health.
Thank you for your participation. If you signed the paperwork at the on -site health screening, this
information will be sent to your physician. If you did not sign the form, you may stop by our clinic to
sign this or have your physician call for the results.
Stay Healthy!
Sincerely,
Judith B. Page, DO
Medical Director