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4. Copy of Health History Form

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Kate Veronica Sanchez
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5 views

4. Copy of Health History Form

Uploaded by

Kate Veronica Sanchez
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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Name: Branch/Dept:

Position: Date Hired:


Employment Status: ID Number:
Date:
Height:

HEALTH HISTORY

Please check the appropriate column for your responses.


Do you have or have you had in the past: YES NO If YES, give details and dates:
A. Conditions of the Lungs?
Asthma? Bronchitis? Pluerisy? TB?
Other chest complaints? Coughing up blood?
Shortness of breath? Any other conditions
B. Conditions of the heart?
High BP? Heart Attacks? Angina?
C. Nervous System Disorder?
Blackouts? Epilepsy? Muscular weakness?
Paralysis?
D. Migraine or persistent headaches?
E. Conditions of the digestive system?
Irritable Bowel Syndrome?
Liver Complaints/jaundice?
Gallbladder Complaints?
Colitis? Gastric/duodenal ulcer?
F. Conditions of the kidney or bladder?
Urinary infection? Kidney Stones?
G. Conditions of the bones, joints and limbs?
Arthritis? Rheumatism? Back problems?
Neck or shoulder problems? Sciatica?
Upper limb disorder? Any othe conditions?
H. Conditions of the Blood/Lymphatic?
Leukemia? Unexplained growth of nodules?
Anemia?
I. Allergies? (Including allergies to drugs,
animals, and pollens).
J. Skin Conditions?
Eczema? Dermatitis? Psoriasis? Recent
infection? Skin Cancer?
K. Gland Trouble
Diabetes? Thyroid overactive/underactive?
L. Eye conditions?
Restricted vision? Glaucoma? Iritis?
Any other condition?
M. Ear Conditions?
Restricted hearing? Tinnitus? Ear infections?
N. Alcohol or drug problems?
Problems related to alcohol or drug usage or
dependency?
O. Mental Illness and/or stress related problems?
Nervous breakdown? Mental fatigue? Anxiety?
Depression? Panic Attacks?Siginificant sleep
disturbance? Stress related problems? Eating
disorders? Self harm? Any other conditions?
P. Reproductive System Infections and abnormalities?
STD's? Myomas? BPH? H-mole? Ca?
Q. Plans to get married? If yes, probably when? ___________________
Plans to have a family? If yes, probably when? ___________________
Note: Should you decide to get married or have a family within the
next months, please notify HRMD upon your decision/ knowledge
R. Have you consulted a specialist or needed any
operations other than already started?
S. Have you spent any time in hospital other than
already started?
T. Are you receiving medical treatment at the present
time?
U. Do you take any regular medication?
V. Have you had any disabilities affecting sight, hearing,
standing, sitting, walking, lifting, driving, stair
climbing, use of the hands or ability to carry
which you would like to provide further details?
W. Have you had any disabilities affecting sight,
hearing, standing, sitting, walking, lifting, driving,
stair climbing, use of hands or ability to carry out
any work?
X. Have you had any other health issues that have
not been mentioned above or about you which
you would like to provide further details?

DECLARATION

1. I Declare that, to the best of my knowledge, the information I have given is correct.

2. I understand that I may be required to undergo a medical examination.

3. I understand that failure to disclose relevant information or giving false information may result in the
termination of my employment.

Signature _________________________ Date ___________________

MEDICAL ASSESSMENT: PRE-EMPLOYMENT

In my opinion, the above is:

1. Medically suitable for employment in the proposed occupation.

2. Medically unsuitable for employment in the proposed occupation.

3. Medically suitable for employment in the proposed occupation, subject to the following conditions:

_________________________________________________________________________________

Signature _________________________ Date ___________________

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