Medical Evaluation Form - Golden Dreams Home Care Llc printable pdf download

Medical Evaluation Form - Golden Dreams Home Care Llc

MEDICAL EVALUATION FORM

FOR GOLDEN DREAMS HOMECARE, L.L.C.. PERSONNELL

To be completed by the Employee

Page 1

PERSONAL DETAILS

SURNAME :

FORENAMES:

ADDRESS:

MARITAL STATUS

DATE OF BIRTH:

Position:

NATIONALITY:

GENDER:

SOCIAL / OCCUPATIONAL HISTORY

1. Do you smoke? If so how many per day

2. If an ex-smoker, when did you give it up?

3. Average weekly alcohol consumption: state quantity and type

4. Have you been exposed to any known occupational hazard

such as noise, radiation, dust, asbestos, chemicals or lead?

5. Are you able to lift 50 pounds?

6. Have you ever developed any medical condition in connection

with your occupation? If so please give details e.g. Hearing

loss/skin condition /wheeze/backache/muscle strain/blood

disease?

7. Have you suffered any occuvational injury?

If so please give details.

8. Are you physically able to bend and stoop?

9. Have you been hospitalised in the last five years? If yes

please rovide details?':

10. Do you have any disabilities?

Use a separate sheet if required

11. Have you ever been rejected from employment or insurance on

medical grounds?

12. Have you received compensation for an occupational claim /or

is there any occupational claim pending?

Medical Evaluation Form - Golden Dreams Home Care Llc