Health Assessment "*" indicates required fields Name* First Last Today's Date* MM slash DD slash YYYY Phone*Email* Date of Birth* MM slash DD slash YYYY Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Social Security Number* Primary Care Physician Primary Care Physician Location City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State In case of emergency, notify:* First Last Relationship PhoneWhat is your usual occupation? Position offered Are you physically fit? Yes No Height Weight Date of last dental exam* MM slash DD slash YYYY Date of last tetanus shot* MM slash DD slash YYYY Have you seen a doctor in the past 5 years?* Yes No If so, when and reason for visit(s) Are you currently receiving medical treatment?* Yes No If Yes, describe Are you currently taking medication of any kind?* Yes No If Yes, describe Are you allergic to any medications?* Yes No If Yes, describe Have you been refused employment or had to leave a job, either temporarily or permanently, because of Sensitivity to chemicals, dust, sunlight, etc. Inability to perform certain motions Inability to assume certain physical positions Other medical reasons No If Other, please provide detail* Have you had or been advised to have any surgical procedures?* Yes No If Yes, please provide detail* Have you ever been treated at a hospital or hospitalized for any reason whatsoever?* Yes No If Yes, please provide detail* Do you have any physical discomfort when you work in dampness or cold?* Yes No If Yes, please provide detail* Has your work ever been restricted on account of your health?* Yes No If Yes, please provide detail* Do you have any condition requiring a special work assignment or limitation?* Yes No If Yes, please provide detail* Do you have any problem which would restrict or make more difficult repetitive lifting or any other heavy physical labor?* Yes No If Yes, please provide detail* Have you ever been a party in a lawsuit for a personal injury, industrial injury or made claim(s) for injury under maritime law?* Yes No If Yes, please provide detail* Have you ever been denied employment for medical reasons?* Yes No If Yes, please provide detail* Have you ever been rejected or discharged from military service for medical reasons?* Yes No If Yes, please provide detail* Have you ever been denied an insurance policy for medical reasons?* Yes No If Yes, please provide detail* Have you ever been exposed to toxic chemicals, vapors, fumes, mists, dusts, radiation or excessive noise?* Yes No If Yes, please provide detail* Treated for mental condition?* Yes No If Yes, please provide detail* Do you drink?* Yes No If Yes, please provide detail* Do you use recreational drugs?* Yes No If Yes, please provide detail* Do you smoke?* Yes No If Yes, please provide detail* Have you ever had, or do you currently have, any of the following:Dizziness, vertigo, fainting spells, balance disorder* Yes No Please explain:*Seizures/epilepsy* Yes No Please explain:*Sinusitis, sinus problems* Yes No Please explain:*Disorder of eyes/ears/nose/throat* Yes No Please explain:*Ear disease, injury, surgery* Yes No Please explain:*Poor vision, corrective lenses for vision?* Yes No Please explain:*Allergies, hay fever, allergic reactions* Yes No Please explain:*Chronic cough, sore throat* Yes No Please explain:*Tuberculosis* Yes No Please explain:*Aneurysm or blockages* Yes No Please explain:*Collapsed lung/pneumothorax* Yes No Please explain:*Heart attack/myocardial infarction* Yes No Please explain:*Heart surgery/stent/angioplasty* Yes No Please explain:*Heart murmur, valve replacement* Yes No Please explain:*High or low blood pressure /hypertension* Yes No Please explain:*Rheumatic fever* Yes No Please explain:*Crohn's disease, ulcerative colitis or IBS* Yes No Please explain:*Intestinal surgery* Yes No Please explain:*Cramps* Yes No Please explain:*Kidney disease, transplant, cancer or dialysis* Yes No Please explain:*Kidney stone(s) or bladder problems* Yes No Please explain:*Hemophilia or polycythemia* Yes No Please explain:*Any form of cancer* Yes No Please explain:*Diabetes* Yes No Please explain:*Shooting pains* Yes No Please explain:*Carpal tunnel/wrist discomfort* Yes No Please explain:*Foot problem(s)* Yes No Please explain:*Skin disease, rash, burns, tumors or cysts* Yes No Please explain:*Back problems, complaint, or injury* Yes No Please explain:*Herniated or ruptured disc* Yes No Please explain:*Sciatica or nerve pain* Yes No Please explain:*Problems of upper or lower extremities* Yes No Please explain:*Lumps, pain, numbness or tingling in hands or wrists* Yes No Please explain:*Locking fingers* Yes No Please explain:*Arthritis, rheumatism or bursitis* Yes No Please explain:*Broken, dislocated bones/joints* Yes No Please explain:*Bone or joint surgery* Yes No Please explain:*Head injury or skull fracture* Yes No Please explain:*Stroke or TIA* Yes No Please explain:*Loss of memory or amnesia* Yes No Please explain:*Depression, schizophrenia, anxiety* Yes No Please explain:*Psychiatric disease, counseling or mental disorders* Yes No Please explain:*Rectal disease, hemorrhoids* Yes No Please explain:*HIV or AIDS* Yes No Please explain:*Motion/sea sickness* Yes No Please explain:*Frequent headaches. migraines* Yes No Please explain:*Thyroid disease* Yes No Please explain:*Hearing loss, hearing aid* Yes No Please explain:*Glaucoma* Yes No Please explain:*Asthma* Yes No Please explain:*Emphysema or COPD* Yes No Please explain:*Shortness of breath, breathing problem(s* Yes No Please explain:*Hernia problems/surgery* Yes No Please explain:*Pulmonary embolus or blood clots* Yes No Please explain:*Chest pain, pressure or angina* Yes No Please explain:*Congestive heart failure* Yes No Please explain:*Pacemaker or defibrillator* Yes No Please explain:*Irregular heartbeat, palpitations* Yes No Please explain:*Any other Heart problem(s), pain/pressure in chest* Yes No Please explain:*Frequent indigestion* Yes No Please explain:*Gastrointestinal bleeding or ulcers* Yes No Please explain:*Any other stomach, liver or intestinal trouble* Yes No Please explain:*Hepatitis, jaundice or other liver problems* Yes No Please explain:*Frequent, painful or difficult urination* Yes No Please explain:*Anemia* Yes No Please explain:*Any other disease or disorder of the blood* Yes No Please explain:*Lymphoma or Leukemia* Yes No Please explain:*Low blood sugar* Yes No Please explain:*Tingling/numbness in any part of body* Yes No Please explain:*Wear any form of brace/support* Yes No Please explain:*Bleeding disorders* Yes No Please explain:*Varicose veins or leg pains* Yes No Please explain:*Back surgery or injury* Yes No Please explain:*Pain or numbness in legs* Yes No Please explain:*Recurrent neck or back pain or problem(s)* Yes No Please explain:*Knee problem(s)* Yes No Please explain:*Swelling of legs, ankles, hands or wrists* Yes No Please explain:*Tendonitis* Yes No Please explain:*Discomfort, sprains of joints* Yes No Please explain:*Amputation or prosthesis* Yes No Please explain:*Neurofibromatosis* Yes No Please explain:*Brain tumor or disease/nerve disease* Yes No Please explain:*Nervous trouble of any sort* Yes No Please explain:*ADD, ADHD or bipolar* Yes No Please explain:*Attempted suicide* Yes No Please explain:*Gall bladder problems/surgery* Yes No Please explain:*Sexually transmitted disease (STD)* Yes No Please explain:*Sleep apnea, nacrolepsy, other sleep disorders* Yes No Please explain:*Have you had any illness(es) or injuries other than those already listed?* Yes No Please explain:*Signature*I certify that the facts and my answers on this questionnaire are true and complete to the best of my knowledge. 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