Health Assessment 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Social Security Number* Primary Care Physician Primary Care Physician Location City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest 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:Check all that apply Dizziness, vertigo, fainting spells, balance disorder Motion/sea sickness Seizures/epilepsy Frequent headaches. migraines Sinusitis, sinus problems Thyroid disease Disorder of eyes/ears/nose/throat Hearing loss, hearing aid Ear disease, injury, surgery Glaucoma Poor vision, corrective lenses for vision? Asthma Allergies, hay fever, allergic reactions Emphysema or COPD Chronic cough, sore throat Shortness of breath, breathing problem(s Tuberculosis Hernia problems/surgery Aneurysm or blockages Pulmonary embolus or blood clots Collapsed lung/pneumothorax Chest pain, pressure or angina Heart attack/myocardial infarction Congestive heart failure Heart surgery/stent/angioplasty Pacemaker or defibrillator Heart murmur, valve replacement Irregular heartbeat, palpitations High or low blood pressure /hypertension Any other Heart problem(s), pain/pressure in chest Rheumatic fever Frequent indigestion Crohn's disease, ulcerative colitis or IBS Gastrointestinal bleeding or ulcers Intestinal surgery Any other stomach, liver or intestinal trouble Cramps Hepatitis, jaundice or other liver problems Kidney disease, transplant, cancer or dialysis Frequent, painful or difficult urination Kidney stone(s) or bladder problems Anemia Hemophilia or polycythemia Any other disease or disorder of the blood Any form of cancer Lymphoma or Leukemia Diabetes Low blood sugar Shooting pains Tingling/numbness in any part of body Carpal tunnel/wrist discomfort Wear any form of brace/support Foot problem(s) Bleeding disorders Skin disease, rash, burns, tumors or cysts Varicose veins or leg pains Back problems, complaint, or injury Back surgery or injury Herniated or ruptured disc Pain or numbness in legs Sciatica or nerve pain Recurrent neck or back pain or problem(s) Problems of upper or lower extremities Knee problem(s) Lumps, pain, numbness or tingling in hands or wrists Swelling of legs, ankles, hands or wrists Locking fingers Tendonitis Arthritis, rheumatism or bursitis Discomfort, sprains of joints Broken, dislocated bones/joints Amputation or prosthesis Bone or joint surgery Neurofibromatosis Head injury or skull fracture Brain tumor or disease/nerve disease Stroke or TIA Nervous trouble of any sort Loss of memory or amnesia ADD, ADHD or bipolar Depression, schizophrenia, anxiety Attempted suicide Psychiatric disease, counseling or mental disorders Gall bladder problems/surgery Rectal disease, hemorrhoids Sexually transmitted disease (STD) HIV or AIDS Sleep apnea, nacrolepsy, other sleep disorders The above conditions:* I attest that the conditions marked above are true and correct. I attest that I have none of the above conditions Please explain the details of any checked items aboveHave you had any illness(es) or injuries other than those already listed?* Yes No If Yes, explain fully and indicate when you had such illness(es) or injuries:READ CAREFULLY BEFORE SIGNING*I certify that the facts and my answers on this questionnaire are true and complete to the best of my knowledge. I understand that any falsifications, misrepresentations or omissions will be cause for withdrawal of conditional job offer or immediate termination regardless of when or how discovered. The terms “misrepresentation” or “omission” include failure to complete this questionnaire form. It is the company policy that inadequately completing company documents may be grounds for denial of employment, withdrawal of a conditional job offer or immediate termination. Inadequate completion includes drawing a line through all “NO” responses since this indicates failure to appropriately consider the company’s request for information. Additionally, false or misleading answers may be a basis for denial of benefits under federal maritime law, denial of maintenance and/ or cure, or any otherwise applicable benefits. Providing thorough and accurate information is required. I certify that the facts and my answers on this questionnaire are true and complete to the best of my knowledge. Δ
