Language
English (US)
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Patient Information
Name
First Name
Last Name
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Date of Birth
/
Month
/
Day
Year
Gender
Male
Female
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Social Security Number
Job Title
Type of exam
Post offer
Periodic or annual
Employer Name
Employer Contact Person
Employer Phone Number
Format: (000) 000-0000.
Employer Email
example@example.com
Patient Signature
DATE
/
Month
/
Day
Year
Back
Next
Medical Questionnaire
Do you have/have you had any of the following
Allergies
Yes
No
Chronic Cough
Yes
No
Asthma, Bronchitis
Yes
No
Tuberculosis
Yes
No
Coughing up blood
Yes
No
Sleep apnea
Yes
No
Had an MRI
Yes
No
When was the MRI done?
-
Month
-
Day
Year
Date
Do you have any history of motor vehicle accidents?
Yes
No
Please explain:
Do you have any past athletic injuries?
Yes
No
Please explain:
How much can you comfortably lift?
Any other health problems the require routine medical care?
Yes
No
Have you had any CAT scans?
Yes
No
When was the CAT scan done?
-
Month
-
Day
Year
Date
Have you ever worked in an environment with asbestos, lead, chemicals?
Yes
No
Last menstrual cycle:
-
Month
-
Day
Year
Date
Last GYN exam:
-
Month
-
Day
Year
Date
Are you pregnant?
Yes
No
Do you smoke now?
Yes
No
How much do you smoke?
Number of years that you have smoked?
If you have stopped, when?
-
Month
-
Day
Year
Date
Do you drink alcohol?
Yes
No
How many drinks per week?
Are you currently or have you been treated for substance abuse?
Yes
No
Are you sensitive/allergic to latex?
Yes
No
Please list any medications that you are allergic to:
Have you ever filed a workmans' comp claim?
Yes
No
Please explain:
Have you ever been limited to restricted work due to your health?
Yes
No
Please explain:
Have you ever lost any time from work in the past 2 years due to illness or injury?
Yes
No
Please explain:
Do you have any medical conditions that require special accommodations for work?
Yes
No
Please explain:
Have you ever had to change jobs because of work related to injury or illness?
Yes
No
Please explain:
Do you have any health concerns related to this job?
Yes
No
Please explain:
Do you have any hobbies, crafts, or side jobs in which you do regularly?
Yes
No
Please explain:
Do you have any current work restrictions?
Yes
No
Please explain:
Please list all of the current medications that you are on:
Do you have/have you had:
Rows
Yes
No
Eczema or Dermatitis
Skin rash or infection
Hives
Difficulty Hearing
Ear disease
Chest pain
Heart attack
High blood pressure
Shortness of breath
Swelling of your ankles
Heart murmur
Heart palpitations
Heart surgery
Pacemaker or defibrillator
Cancer
Back or neck injury or pain
More than 2 episodes of back or neck pain
Associated leg pain
Fall causing back pain
Out of work greater than 5 weeks due to back pain
Slipped discs
Carpal tunnel Syndrome
Shoulder or wrist injuries
Ankle or knee injury
Swollen joints
Arthritis or gout
Epicondylitis
Bursitis, tendonitis
Trouble walking or standing
Trouble sitting
Arm or leg numbness
Dizziness or fainting
Muscle weakness
Deficiency of Immune System
Frequent headaches
Migraines
Seizures or Convulsions
Multiple Sclerosis
Nerve damage
Liver problems
Hepatitis A, B, or C
Cirrhosis
History of jaundice
Stomach pain or ulcers
Other intestinal problems
Excessive weight loss
Anemia or fatigue
Recurrent sore throats
Night sweats
Diabetes
Thyroid trouble or goiter
Kidney problems
Stress anxiety or depression
Job with repetitive motion
Job with vibratory tools
Do you exercise regularly?
Do you use contacts?
Are you colorblind?
Do you have cataracts?
Do you work with lasers?
Does your skin react to:
Rows
Yes
No
Chemicals
Latex gloves
Soaps/detergents
Bleaches
Do you use glasses for:
Rows
Yes
No
Reading
Distance
Have you had any of the following surgeries:
Rows
Yes
No
Back or neck
Shoulder
Arm, wrist, hand or elbow
Knee, leg, ankle or foot
Abdominal surgery
Hernia repair
Nerve Surgery
Do you have weakness of:
Rows
Yes
No
Arm, wrist, or hand
Knee, leg, or foot
Please explain any questions answered YES
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