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Call Today (347) 476-8262

Office Number:- (718) 465-5151

Get Started

Employee Health Assessment

Form Introductory Text

Name

First Name*

Last Name*

Sex

Male Female

Date

Emergency Contact

Relationship

Emergency Address

Telephone

Email*

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

Diabetes

Yes No

Kidney Disease

Yes No

Heart Disease

Yes No

Latex Allergy

Yes No

High Blood Pressure

Yes No

Arthritis

Yes No

Tuberculosis

Yes No

Mental Illness

Yes No

Epilepsy/Convulsions

Yes No

Cancer

Yes No

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

Chest Pain

Yes No

Lingering Cough

Yes No

Loss of Energy

Yes No

Unexplained Weight Loss in past year

Yes No

Blood in Sputum

Yes No

Increased Sweating at Night

Yes No

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

Migraine Headaches

Yes No

Fainting or Dizziness

Yes No

Weight Gain/Loss of 15+ lbs.

Yes No

Change in Energy Level

Yes No

Frequent Cough

Yes No

Blood in Sputum

Yes No

Shortness of Breath

Yes No

Chest Pain/ Pressure in Chest

Yes No

Swelling in Legs/Feet

Yes No

Pain in calf when walking

Yes No

Change in bowel habits

Yes No

Back Pain

Yes No

Pain when urinating or blood in urine

Yes No

High Blood Pressure

Yes No

Infectious Disease

Yes No

Increased Thirst

Yes No

Persistent Sores/ Lumps

Yes No

Are you a smoker?

Yes No

If yes. please state frequency and packs per day

Do you drink alcoholic beverages?

Yes No

If yes. please state frequency and amount

Do you take antidepressants, stimulants, or narcotic drugs?

Yes No

If yes, please specify

Do you take prescription medications?

Yes No

If yes, please specify

Name of Physician

Address

Telephone

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.

Signature

Date

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About

Vesretta Homecare LLC was founded with the mission to provide compassionate and professional in-home care to the residents of Queens and Nassau County.

Contact Us

(347) 476-8262

Office Number:- (718) 465-5151

janet@vesretta.com

61-43 186th St Suite 206, Fresh Meadows, NY 11365, United States

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