POST –JOB OFFER MEDICAL HISTORY QUESTIONNAIRE



[pic] Human Resources, Inc. & Subsidiaries

Including Human Resources International, Inc., HR Specialists, Inc., Human Resources Management, Inc.

and Design HR, Inc. hereinafter referred to as “HRI”

This Medical History Questionnaire is required of all employees who have been given a conditional offer of employment with this worksite employer. The information provided will be kept in confidence and maintained consistent with the terms of the Americans with Disabilities Act and will not be used to discriminate against qualified individuals with a disability in any phase of employment, including hiring, advancement, transfer, wages, job training, and /or under terms, conditions, or privileges of employment. The job offer, which you have received from this employer, is “conditioned” upon the results of this medical history statement and/or any job specific medical exam required. This questionnaire should not be answered unless the applicant initials here _____ that he/she has received a conditional offer of employment and has not commenced work for the worksite employer.

|Worksite Employer |      |

|Last Name |      |First Name |      |MI |      |

|Address |      |

|City |      |State |      |Zip |      |

|Home Phone |      |Work Phone |      |County |      |

|Birth Date |      |Height |      |Weight |      |

|Social Security # |      |Driver’s License # |      |State |      |

Any false statements, misrepresentations, or concealment to secure employment are sufficient grounds for dismissal and/or denial of workers’ compensation benefits as allowed by law.

Medical History

Answer each question as stated below “Yes” or “No” by placing an (X) in the space indicated. If you answer “Yes” to any of these questions, give additional details in the space provided.

| |YES |NO | |YES |NO |

|Heart Disease | | |Hearing Problems | | |

|Rheumatic Fever | | |Mastoid Operation | | |

|High Blood Pressure | | |Frequent Headaches | | |

|Varicose Veins | | |Diabetes | | |

|Chest Pains | | |Eye Injury | | |

|Head Injury | | |Chronic Cough | | |

|Dizziness | | |Epilepsy | | |

|Tuberculosis | | |Frequent Backaches | | |

|Allergies | | |Arthritis | | |

|Skin Disorder | | |Amputation | | |

|Reaction to Drug | | |Bladder Problem | | |

|Kidney Disorder | | |Nervous Condition | | |

|Ulcer | | |Cancer | | |

|Job Title      |

|Job Description       |

|      |

|      |

|Do you have any limitation that may affect your ability to safely or effectively perform the position you have been | Yes | No |

|offered?  | | |

|If yes, please describe in the space below |

|      |

|      |

| |

|Are you unable to perform certain body motions or assume certain body positions? | Yes | No |

|Have you ever been treated or hospitalized for a mental illness? | Yes | No |

|Have you ever suffered from a hernia? | Yes | No |If yes, which side? | Left | Right |

| Was it operated on? | Yes | No |If yes, when? |      |

|Do you wear glasses or contact lenses? | Yes | No |All the time? | Yes | No |

|Have you ever suffered an injury to your back or neck? | Yes | No |

| If yes, when? |      |

|If you answered YES to any of the questions in this medical questionnaire, please give additional details in the space below: |

|      |

|      |

All statements and information given in the health questionnaire are true and accurate to the best of my knowledge and belief. I have read and fully understand this form.

Applicant’s Signature Date

Florida Law prohibits retaliation against an individual based upon the filing of a Workers’ Compensation claim.

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POST-JOB OFFER MEDICAL HISTORY QUESTIONNAIRE

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