MEDICAL QUESTIONNAIRE AND EXAMINATION CHECKLIST
MEDICAL QUESTIONNAIRE AND EXAMINATION CHECKLIST
This checklist will assist in ensuring that all required information needed for employment physicals is provided by the Member and the Licensed Physician to the LOPFI-covered employer.
Applicant Name:____________________________
Last 4 of SS#_____________
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licensed physician)
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_A_p_p__li_c_a__n_t_s__P__ri__n_t_e_d___N__a_m___e_____________________________________A__p__p_l_ic__a_n_t__s__S_i_g_n_a__tu__r_e___________________________________D__a_t_e_______
Applicants Printed Name
Signature
Date
PHYSICIAN COMPLETES Review completed Medical Questionnaire provided by applicant Review Job Description and Duties provided by applicant Properly complete the Medical Examination Report
(By providing your signature below you certify that you have reviewed the job description and the Medical Questionnaire and properly completed the Medical Examination Report.)
_______________________ _______________________________
Physician's Printed Name
Signature
___________
Date
EMPLOYER COMPLETES Review completed Medical Questionnaire
Any notable conditions/concerns? No Yes _________________________________ Review Medical Examination Report
Any notable conditions/concerns? No Yes _________________________________
(By providing your signature below you certify that you have received the completed Medical Questionnaire and Medical Examination Report and shall retain all documents in applicant's file.)
________________________ ____________________________
Employer Representative Printed Name
Signature
___________
Date
This checklist was designed as an aid with pre-employment physicals for applicants seeking employment with a LOPFI-covered employer. Please contact the employer directly with any questions regarding your pre-employment physical.
Form DC115
MEDICAL QUESTIONNAIRE
Instructions to applicants: Complete this form prior to your physical examination and give to the examining physician along with a copy of the Job Description for the LOPFI-covered position you have applied.
Applicant's Name (Last, First, Middle) Address
Last 4 of SSN
Date of Birth
Age
Current Occupation
SECTION A: HAVE YOU EVER OR DO YOU NOW HAVE ANY OF THE FOLLOWING? FOR "YES" ANSWERS, SUPPLY FULL DETAILS ON
RIGHT SIDE OF PAGE OR SECTION B.
General: 1. Decreased exercise tolerance? 2. Fatigue? 3. Weight change? (plus/minus 10 lbs)
Gain Loss 4. Change in Appetite?
YES NO ________________________________________________ YES NO ________________________________________________ YES NO ________________________________________________ YES NO ________________________________________________ YES NO ________________________________________________
Integumentary (Skin): 5. Changes in moles? 6. Rash? 7. Changes in skin/hair/nails? 8. Ulcers/Sores?
YES NO ________________________________________________ YES NO ________________________________________________ YES NO ________________________________________________ YES NO ________________________________________________
Eyes: 9. Do you wear glasses/contact lenses? 10. Do you have blurred vision? 11. Flashes of light? 12. Vision halos? 13. Do you have a history of cataracts? 14. Glaucoma? 15. Blindness?
Right eye? Left eye? Both?
YES NO ________________________________________________ YES NO ________________________________________________ YES NO ________________________________________________ YES NO ________________________________________________ YES NO ________________________________________________ YES NO ________________________________________________ YES NO ________________________________________________
Ear, Nose, Mouth and Throat: 16. Do you have any hearing loss?
Right ear? Left ear? Both? 17. Hearing aid? 18. Do you wear dentures/braces? 19. Teeth problems? 20. Chronic sinus problems?
Pain? Congestion? 21. Do you have frequent nose bleeds? 22. Deviated septum? 23. Hoarseness/Changes in voice? 24. Sore throat? 25. Bleeding gums? 26. Trouble swallowing? 27. Lump/masses?
YES NO ________________________________________________
YES NO ________________________________________________ YES NO ________________________________________________ YES NO ________________________________________________ YES NO ________________________________________________
YES NO ________________________________________________ YES NO ________________________________________________ YES NO ________________________________________________ YES NO ________________________________________________ YES NO ________________________________________________ YES NO ________________________________________________ YES NO ________________________________________________
Respiratory:
28. Do you wheeze?
29. Do you have a chronic cough?
30. Have you coughed up blood?
31. Do you experience shortness of breath?
At rest?
With activity?
32. Do you snore?
33. COPD?
34. Pneumonia?
35. Asthma?
36. Lung disease?
YES NO ________________________________________________ YES NO ________________________________________________ YES NO ________________________________________________ YES NO ________________________________________________
YES NO ________________________________________________ YES NO ________________________________________________ YES NO ________________________________________________ YES NO ________________________________________________ YES NO ________________________________________________
Form DC116
Page 1 of 4
Cardiovascular:
37. Chest pain, pressure or tightness?
YES
At rest? With activity?
38. Heart palpitations (racing)?
YES
39. Irregular heartbeats?
YES
40. Short of breath lying flat?
YES
41. Have you passed out?
YES
42. Swelling of feet or ankles?
YES
43. Pain in legs with walking?
YES
44. Heart failure?
YES
45. Heart attack?
YES
46. Cardiac arrhythmia?
YES
47. Heart murmur or prolapse?
YES
48. Blood pressure problems? High? Low? YES
49. Stroke?
YES
50. Fainting spells?
YES
Gastrointestinal System:
51. Frequent nausea and/or vomiting?
YES
52. Abdominal pain?
YES
53. Black, tarry stool?
YES
54. Bright red blood in stool?
YES
55. History of stomach ulcers?
YES
56. Frequent diarrhea?
YES
57. History of gallbladder problems?
YES
58. History of liver problems?
YES
Genitourinary:
59. Do you have pain with urination?
YES
60. Sense of urgency to urinate?
YES
61. Awaken frequently to urinate?
YES
62. History of bladder, kidney infection?
YES
63. History of kidney stones?
YES
64. Males: Prostate problems?
YES
65. Females: Post menopausal?
YES
66. Currently taking hormone replacement?
YES
Musculoskeletal:
67. Chronic back pain?
YES
68. Arthritis?
YES
69. History of gout?
YES
70. Joint pain or stiffness?
YES
71. Limited joint movement?
YES
72. Muscle pain or cramps?
YES
73. Muscle weakness?
YES
74. History of blood clots in legs?
YES
75. History of varicose veins?
YES
Neurological:
76. Temporary blurred vision/loss of vision?
YES
77. Temporary weakness, numbness and/or tingling YES
involving an arm or leg?
78. Severe headaches?
YES
79. Migraine headaches?
YES
80. Convulsions/Seizures?
YES
81. Epilepsy?
YES
82. Tremors?
YES
Endocrine:
83. High cholesterol?
YES
84. Diabetes?
YES
85. Thyroid problems?
YES
_________________________
Applicant's Name
NO ________________________________________________
NO ________________________________________________ NO ________________________________________________ NO ________________________________________________ NO ________________________________________________ NO ________________________________________________ NO ________________________________________________ NO ________________________________________________ NO ________________________________________________ NO ________________________________________________ NO ________________________________________________ NO ________________________________________________ NO ________________________________________________ NO ________________________________________________
NO ________________________________________________ NO ________________________________________________ NO ________________________________________________ NO ________________________________________________ NO ________________________________________________ NO ________________________________________________ NO ________________________________________________ NO ________________________________________________
NO ________________________________________________ NO ________________________________________________ NO ________________________________________________ NO ________________________________________________ NO ________________________________________________ NO ________________________________________________ NO ________________________________________________ NO ________________________________________________
NO ________________________________________________ NO ________________________________________________ NO ________________________________________________ NO ________________________________________________ NO ________________________________________________ NO ________________________________________________ NO ________________________________________________ NO ________________________________________________ NO ________________________________________________
NO ________________________________________________ NO ________________________________________________
NO ________________________________________________ NO ________________________________________________ NO ________________________________________________ NO ________________________________________________ NO ________________________________________________
NO ________________________________________________ NO ________________________________________________ NO ________________________________________________
Page 2 of 4
Hematological/Immunologic: 86. Chronic low blood count/anemia? 87. Bleeding problems? 88. Allergies? 89. Blood Disease (Leukemia)? 90. Blood Clots/DVT? 91. Tuberculosis? 92. Hepatitis? 93. Cancer? 94. Lupus? 95. Steroid Medications?
Psychiatric: 96. History of depression? 97. Anxiety? 98. Panic attacks? 99. History of drug or alcohol abuse? 100. Trouble sleeping? 101. Thoughts of suicide? 102. Decreased appetite? 103. Increased appetite? 104. Eating disorder? 105. Loss of sense of humor? 106. Less ability to enjoy regular activities? 107. Tearfulness? 108. Lack of concentration? 109. Irritability? 110. Loss of energy? 111. Lowered self esteem? 112. Less interest in daily grooming?
(bathing, shaving, wash hair, etc) 113. Mania? 114. Hearing voices? 115. Obsessive thoughts? 116. Compulsive behavior?
_________________________
Applicant's Name
YES NO ________________________________________________ YES NO ________________________________________________ YES NO ________________________________________________ YES NO ________________________________________________ YES NO ________________________________________________ YES NO ________________________________________________ YES NO ________________________________________________ YES NO ________________________________________________ YES NO ________________________________________________ YES NO ________________________________________________
YES NO ________________________________________________ YES NO ________________________________________________ YES NO ________________________________________________ YES NO ________________________________________________ YES NO ________________________________________________ YES NO ________________________________________________ YES NO ________________________________________________ YES NO ________________________________________________ YES NO ________________________________________________ YES NO ________________________________________________ YES NO ________________________________________________ YES NO ________________________________________________ YES NO ________________________________________________ YES NO ________________________________________________ YES NO ________________________________________________ YES NO ________________________________________________ YES NO ________________________________________________
YES NO ________________________________________________ YES NO ________________________________________________ YES NO ________________________________________________ YES NO ________________________________________________
PSYCHIATRIC HISTORY
Are any of the following areas of your life particularly stressful to you? (Check all that apply)
Marriage/relationship
Health
Legal problems
Financial problems
Family problems
Sexual issues
Please explain:
Employment Violence
Have you ever been treated for a psychiatric illness (depression, anxiety, bipolar, etc.?)
YES
NO
Have you ever been treated in a psychiatric facility?
YES NO
If yes to either of the above questions, please list doctor's names, hospitals, and dates of treatment:
Have you had any of the following? Neurological Exam Psychiatric Exam
Page 3 of 4
YES
NO
YES
NO
_________________________
Applicant's Name
Psychological Testing
YES
NO
Professional counseling/psychotherapy
YES
NO
If you answered YES to any of the above, please list the names of the doctor or therapist and dates seen:
Other medical history not listed above:
PREVIOUS SURGERY (PLEASE LIST ALL SURGERIES. ATTACH ADDITIONAL PAGE(S) IF NEEDED)
Procedure
Date
Hospital
Surgeon
Complications
WRITE YOUR OWN ACCOUNT AND EXPLAIN ALL ITEMS ANSWERED "YES" IN THE QUESTIONNAIRE; IDENTIFY ITEM SECTION B NUMBER, INCLUDE DIAGNOSIS, DATE OF ONSET, AND YOUR PRESENT CONDITION, CONTINUE ON ADDITIONAL
PAGE(S) IF NEEDED.
PENALTY
ANY FALSIFICATION, WITHHOLDING OR FAILURE TO ANSWER ALL QUESTIONS COMPLETELY AND ACCURATELY MAY CAUSE
FORFEITURE OF ALL RIGHTS TO THIS EMPLOYMENT AND/OR LOPFI RETIREMENT BENEFITS.
CERTIFICATION
I HEREBY CERTIFY THAT THERE ARE NO WILLFUL MISREPRESENTATIONS, OMISSIONS OR FALSIFICATIONS IN THE FOREGOING
STATEMENTS AND ANSWERS, AND THAT ALL RESPONSES ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
SIGNATURE OF APPLICANT
DATE SIGNED:
(SIGN IN INK) X_____________________________________________
Page 4 of 4
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