Medical Evaluation Form - Golden Dreams Home Care Llc (Page 2 of 2) in pdf

Medical Evaluation Form - Golden Dreams Home Care Llc Page 2

Employee Name:

Page 2

MEDICAL HISTORY REQUIRING SPECIAL CONSIDERATION

DO YOU HAVE OR HAVE BEEN DIAGNOSED AS SUFFERING FROM ANY OF THE FOLL0WING:

Please include any family history of the following in addition

Please Elaborate

1. Chest pain / heart disease

YES

2. High blood pressure / stroke

YES

3. Asthma / epilepsy / diabetes

YES

4. Peptic ulcer disease

YES

5. Kidney disease (eg. Stones )

YES

6. Psychiatric disorder eg. anxiety,

YES

Depression

7. Tuberculosis

YES

8. Cancer

YES

9. Have you or anyone in your family an

YES

existing medical condition?

Vaccination history

10.

Poliomyelitis

Tetanus

Hep. A

Hep. B

BCG

Meningitis

Approx. Date:

DECLARATION

PLEASE READ THE FOLLOWING STATEMENT AND IF YOU AGREE, SIGN AND DATE.

“I DECLARE THE ABOVE TO BE TRUE TO THE BEST OF MY KNOWLEDGE.

I ACCEPT THAT GOLDEN DREAMS HOMECARE, L.L.C. IS NOT LIABLE

FOR ANY PRE-EXISTING MEDICAL CONDITION IN MYSELF OR MY

DEPENDENTS UNLESS EXPRESSELY STATED IN WRITING”.”

Employee Signature_____________________________________________Date_______________________________

Medical Evaluation Form - Golden Dreams Home Care Llc Page 2