10. HEALTH HISTORY

HEALTH HISTORY

TO BE COMPLETED BY EMPLOYEE
Have you had, or do you have any of the following conditions:
Please explain any condition(s) circled/checked
History of accidents, fractures, illness, operations
Are you now taking medications prescribed by a physician?
If yes, which medications
Have you ever had an illness caused by any type of work?
If yes, which explain
I certify that the above answers are true to the best of my knowledge. I understand that this assessment is for employment purpose, not for diagnosis/treatment. Nor does it replace my physical examination.
Print Name
Employee Signature
Date

MonthDayYear
Date
Should be Empty: