Occupational Health History/exam Form
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4OCCUPATIONAL HEALTH HISTORY/ EXAM
Prior to your exam please complete the next three pages.
Sign your name at the bottom of the third page.
The health care provider will review the information
and complete the fourth page.
THIS EXAMINATION IS TO DETERMINE WORK CAPABILITIES ONLY.
IT IS NOT INTENDED TO TAKE THE PLACE OF A REGULAR
EXAMINATION BY YOUR PRIVATE HEALTH CARE PROVIDER.
Full Name: _____________________________________________________Date of Birth: _____________________________
Phone:_______________________________________Social Security Number: ______________________________________
Address: ______________________________________________________________________________________________
City:________________________________________________State:___________________ Zip: _______________________
Company:________________________________________Position Applied For: _____________________________________
Please check list below and complete:
HAVE YOU EVER HAD:
Yes
No Year
Yes
No Year
Head injury, skull fracture, whiplash
Gallstones
Headaches, dizzy or fainting spells
Kidney problems, frequent urination
Mental, nervous, brain problems
Hepatitis or jaundice
Convulsions, epilepsy or black-outs
Liver problems
Asthma or allergy
Hernia or rupture
(to food chemicals, medications)
Vision loss, blindness, color blindness
Foot or ankle problems
Ear trouble, decreased hearing
Varicose veins, leg ulcers
Diabetes
Hand, wrist or elbow problems
Frequent nosebleeds
Stiff joints: trick shoulders or knees
Frequent trouble swallowing
Shoulder problems
(rotator cuff etc.)
Hoarseness
Back problems
(injury, strain, herniated disc)
Rheumatic fever
Bursitis, tendonitis
Chronic bronchitis, cough or pneumonia
Rheumatism, arthritis, gout
Tuberculosis or spitting blood
Hospitalizations for illness or injury
Chest pain or shortness of breath
Anemia or bleeding problems
Swelling of legs or ankles
Rash from contact or allergy
Fractures of any degree
High blood pressure or stroke
Stomach trouble, ulcers
Scars or identifying marks
Tumor or Cancer
Do you wear contact lenses
Heart trouble
Muscle disorder
Comments: ____________________________________________________________________________________________
VHFC-PA84071 7-14
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