MAINE DEPARTMENT OF LABOR
MAINE DEPARTMENT OF LABOR
DIVISION OF VOCATIONAL REHABILITATION
HEALTH CHECKLIST
|NAME | |DATE | |AGE | |
ARE YOU LEFT HANDED RIGHT HANDED
A. PLEASE SUMMARIZE THE MOST IMPORTANT PROBLEM THAT INTERFERES WITH YOUR
USUAL TYPE OF WORK. HOW LONG HAVE YOU BEEN BOTHERED AND IS THE PROBLEM
GETTING BETTER OR WORSE?
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B. DO YOU CURRENTLY HAVE DIFFICULTY WITH:
| |YES |NO | |YES |NO |
|1. HEARING | | |19. STANDING | | |
|2. SEEING | | |20. WALKING | | |
|3. SPEAKING | | |21. KNEELING | | |
|4. FAINTING | | |22. SITTING | | |
|5. SEIZURES | | |23. LEARNING | | |
|6. CHEST PAIN | | |24. READING | | |
|7. SHORTNESS OF BREATH | | |25. CONCENTRATING | | |
|8. CHRONIC COUGH | | |26. REMEMBERING | | |
|9. DIGESTION | | |27. GETTING ALONG WITH PEOPLE | | |
|10. GYNECOLOGICAL PROBLEMS | | |28. NERVOUSNESS (ANXIETY/PANIC) | | |
|11. SWELLING OF HANDS/LEGS | | |29. DEPRESSION | | |
|12. WEAKNESS/PAIN IN HANDS/ARMS | | |30. STRESS TOLERANCE | | |
|13. WEAKNESS/PAIN IN LEGS/FEET | | |31. SLEEP | | |
|14. NUMBNESS | | |32. ENERGY/STAMINA | | |
|15. SKIN PROBLEMS | | |33. HALLUCINATION/DELUSION | | |
|16. LIFTING/BENDING | | |34. OTHER | |
|17. CLIMBING (STAIRS) | | | | | |
| | | |35. HAVE YOU EVER BEEN UNCONSCIOUS | | |
|18. BALANCING | | | | | |
C. HAVE YOU EVER HAD, OR BEEN TOLD YOU HAVE:
| |YES |NO | |YES |NO |
|1. HIGH BLOOD PRESSURE | | |8. EATING DISORDER | | |
|2. HEART TROUBLE | | |9. KIDNEY OR URINARY TROUBLE | | |
|3. DEVELOPMENTAL DISABILITY | | |10. ARTHRITIS | | |
|4. ASTHMA OR LUNG DISEASE | | |11. DIABETES | | |
|5. TUBERCULOSIS | | |12. CANCER | | |
|6. GASTROINTESTINAL PROBLEM | | |13. HEPATITIS B & C | | |
|7. PSYCHIATRIC/EMOTIONAL DISORDER | | |14. OTHER INFECTIOUS DISEASES | |
| | | |15. OTHER | |
D. HOW MUCH DO YOU USE:
|TOBACCO | |ALCOHOL | |OTHER DRUGS | |
| | | | |
|DO YOU HAVE A HISTORY OF DEPENDENCY ON DRUGS? | |ALCOHOL | |
|IF SO, PLEASE IDENTIFY YOUR DRUG(s) OF CHOICE? | |
|IF SO, WHAT IS THE DATE OF YOUR SOBRIETY? | |
| | |
|HOW OFTEN DO YOU ATTEND AA, NA, OR OTHER PROGRAMS | |
E. ARE YOU CURRENTLY TAKING ANY MEDICATIONS? (Please mention both prescription & non-prescription or over-the-counter drugs)
|WHAT MEDICINES (Dosage) | PURPOSE (For what condition) |
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F. DO YOU USE A CANE, BRACE, WHEELCHAIR, HEARING AID, OR OTHER ASSISTIVE DEVICE:
|YES NO |PLEASE SPECIFY | |
|DATE: | |SIGNATURE OF APPLICANT | |
|COMMENTS: | |
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