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Annual Health Assessment
Annual Health Assessment
"
*
" indicates required fields
Employee Name
*
Last 4 of SS#
*
Phone
*
Email
*
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Have you had or do you have any of the following conditions/symptoms?
Allergies
*
Yes
No
Arthritis
*
Yes
No
Seizures
*
Yes
No
Diabetes
*
Yes
No
Heart Trouble
*
Yes
No
Exposure to Hepatitis
*
Yes
No
High Blood Pressure
*
Yes
No
Surgery within Past Year
*
Yes
No
Back Trouble
*
Yes
No
Have you had ANY immunizations, such as flu or tetanus shots, in the past year?
*
Yes
No
Please enter the date and type of immunization
Name of a physician you would like us to contact in the event of any emergency or illness:
Name
*
Phone
*
Do you have any health impairment which is of potential risk to the patient, or which might interfere with the performance of your duties, including the habituation or addiction to depressants, stimulants, narcotics, alcohol, ¿or other drugs which may alter your behavior?
*
Yes
No
Please explain the impairment
What is your current weight?
*
What is your current height?
*
Are you currently taking medication prescribed by a physician?
*
Yes
No
What medication and for what reason
Certification
I certify that the information I have provided on this health assessment is true to the best of my knowledge. I understand that this assessment is not for diagnosis or treatment purposes, nor does it replace my physician’s medical examination.
Signature
*
Date
*
MM slash DD slash YYYY
