Pre-employ-health-survey_revised.cdr

1 0 1 5 E . S e m o r a n B l v d , S u i t e 2 0 9 w w w . m e d t e a m s t a ff i n g . c o m PRE-EMPLOYMENT HEALTH SURVEY
This Health Survey is a MEDTEAM STAFFING PRE-EMPLOYMENT REQUIREMENT and is intended to be a work-related assessment of my ability to perform without limitation. I certify that the answers to all survey questions are true and understand that misrepresentation, omission or falsification may prevent an offer of employment, or if employment has been offered, to be withdrawn or terminated.
EMERGENCY NOTIFICATION
Should I be involved in an accident or emergency situation, please notify:
Last Name:____________________________________ First Name :_____________________ Middle Initial:____________ Home Telephone: [ ]____________________________ Business Telephone: [ ]_______________________ Address: _____________________________________________________________________________________________ City: _________________________________________ State: _________________________ Zip: ____________________ PHYSICIAN DESIGNATION
Should I be involved in an accident or emergency situation, please notify:
Last Name:____________________________________ First Name:_____________________ Middle Initial:____________ Home Telephone: [ ]____________________________ Business Telephone: [ ]_______________________ Address: _____________________________________________________________________________________________ City: _________________________________________ State: _________________________ Zip: ____________________ HEALTH CLEARANCE
Should I be involved in an accident or emergency situation, please notify:
The date of my last physical was:_________________________________ Month:_________________ Year:____________ The name and address of the physician and/ or facility that performed the physical: __________________________________ Name:_______________________________________________________________________________________________ Address: ________________________________________ City: ______________ State: _____________ Zip: __________ Telephone: [ ]__________________________________________________________________________________ TB STATUS
The date of my last PPD: Month: Year: Performed where: My last CXR was performed:Month: Year: Performed where: ALLERGIES (known allergy)
Morphine, codeine, demerol or other narcotics/controlled Novocaine, xylocaine, or other anesthetics Do you have any physical condition which might limit your ability to perform the job for which you are applying? Yes No Do you have any physical defects / limitations which precludes you from performing certain job/responsibilities? Yes No ARE YOU NOW OR HAVE YOU EVER SOUGHT TREATMENT FOR
HAVE YOU EVER BEEN
HAVE YOU EVER RECEIVED
Unable to hold a position for health reasons Unable to hold a position for medical reasons Advised to have diagnostic tests that were not completed Advised to have a hospitalization that was not completed Advised to have a surgery which was not completed HAVE YOU EVER
Had any serious illness in the last five years Had your work restricted for health reasons Had treatment or consultation for musculoskeletal injury Is there pending, or have you applied for a pension, or Please explain each yes answer. A separate sheet can be attached.
compensation for any existing disability? Are you taking any medication or substance (prescription or otherwise) that may cause a positive result on a drug test?
If yes, please list all substances (i.e., the migraine medication Imitrex).
I certify that the answers to all survey questions are true and understand that misrepresentation, omission or
falsification may prevent an offer of employment, or if employment has been offered, to be withdrawn or terminated.

Source: http://www.medteamstaffing.com/pdf/pre-employ-health-survey.pdf