Employee Health Assessment

Form Introductory Text

 

Name

Sex


Indicate illnesses experienced by you or family (Yes or No)

Diabetes

Kidney Disease

Heart Disease

Latex Allergy

High Blood Pressure

Arthritis

Tuberculosis

Mental Illness

Epilepsy/Convulsions

Cancer


TB Screen (History and PPD)(Yes or No)

Chest Pain

Lingering Cough

Loss of Energy

Unexplained Weight Loss in past year

Blood in Sputum

Increased Sweating at Night


Indicate any illness experienced since last assessment (Yes or No)

Migraine Headaches

Fainting or Dizziness

Weight Gain/Loss of 15+ lbs.

Change in Energy Level

Frequent Cough

Blood in Sputum

Shortness of Breath

Chest Pain/ Pressure in Chest

Swelling in Legs/Feet

Pain in calf when walking

Change in bowel habits

Back Pain

Pain when urinating or blood in urine

High Blood Pressure

Infectious Disease

Increased Thirst

Persistent Sores/ Lumps


Are you a smoker?

Do you drink alcoholic beverages?

Do you take antidepressants, stimulants, or narcotic drugs?

Do you take prescription medications?

I have carefully read and completed this form, and declare that I have no illness or injury, then listed above that will affect my performance while conducting my job’s responsibilities. I am not addicted to any stimulants, drugs, or narcotics, including anti-depressants, or any other substances that may alter my behavior, including alcohol.