Pre-Employment/job Placement Medical Questionnaire Form printable pdf download

Pre-Employment / Job Placement Medical Questionnaire

Name ___________________________________________________ Date of Birth _______________ Age ______ Sex: M

Address ______________________________________________ City _______________ State __________ Zip ____________

Family Doctor ___________________

Company __________________ Job applied for: _____________________________

** TO BE COMPLETED BY PROSPECTIVE EMPLOYEE PRIOR to appointment

Do you ever have

Have you EVER had:

Reaction to medication ………… Y

Fits or convulsions………………. Y

Blood in urine……………………. Y

Reaction to chemicals …………. Y

Epilepsy or seizures…………….. Y

Kidney trouble…………………… Y

Skin rashes or eczema ……….. Y

Paralysis………………………….. Y

Trouble with urination………….. Y

Have you EVER had

Numbness in hands or feet…….. Y

Have you EVER had:

Asthma ………………………..

Double vision…………………….. Y

Liver trouble……………………… Y

Hay fever or allergies ……….

Severe or disabling headaches… Y

Hepatitis or jaundice……………. Y

Shortness of breath w/walking

Dizzy spells………………………. Y

Do you have:

Tightness in chest ……………

Nervous breakdown…………….. Y

Diabetes………………………….

Tuberculosis ………………….

Have you EVER had:

Thyroid problem or goiter ……..

Emphysema or COPD ………

Back pain for more than

Cancer of any kind……………… Y

1-2 days per month…………… Y

Problem working in dusty job

Problem with anemia……………. Y

Do you

Back injury……………………….. Y

Problem where you bleed easily.. Y

Smoke cigarettes

Back surgery…………………….. Y

Have you ever:

____ pk/day x _____ years

Ruptured or herniated disk …….. Y

Been treated with radiation……... Y

Use other form of tobacco

Knee or hip surgery…………….. Y

Worked with radioactive material Y

Have you every had

Swollen joints……………………. Y

Are or do you:

High blood pressure …………… Y

Dislocated shoulder…………….. Y

Taking any medicine regularly … Y

Heart problem …………………. Y

Rheumatism or arthritis…………. Y

Using any illegal drugs…………. Y

Heart attack ……………………. Y

Fracture of bone…………………. Y

Use alcohol regularly…………… Y

Heart surgery (bypass, stent) … Y

Do you use:

How much? ____________

Swelling in ankles………………. Y

Glasses or contacts for reading.. Y

How often? _____________

Fainting spells / passed out…… Y

Glasses or contacts for distance Y

Have you ever had:

Varicose veins

Are you color blind………………. Y

Restriction of any kind at previous

job …………………..

Do you have

Did you EVER have:

Stomach ulcer ………………….. Y

Ear surgery………………………. Y

Any medical condition aggravated

by work or job?....

Frequent nausea ………………. Y

Difficulty hearing…………………. Y

Frequent bowel trouble ……….. Y

Any other ear trouble……………. Y

Hepatitis shot series…………

Frequent diarrhea ……………… Y

Do you wear hearing aids………. Y

Hernia …………………………… Y

Ringing in ears ………………….. Y

Date of your last tetanus shot? _________

Explanation of ALL “Y” answers:

I hereby declare the answers I have given above are accurate to the best of my knowledge:

X ______________________________________________________ Date _______________________

Physician Comments/Clarifications

Pre-Employment/job Placement Medical Questionnaire Form

Related Articles

Related forms

Related Categories