10. HEALTH HISTORY

HEALTH HISTORY

TO BE COMPLETED BY EMPLOYEE
AllergiesArthritisAsthmaBack TroubleConvulsionsDiabetesDifficulty HearingDifficulty SeeingFainting/Dizzy SpellsGoiterHeat Trouble HepatitisHerniaHigh Blood PressureLow Blood PressureMental IllnessRheumatic FeverSevere HeadachesStomach UlcersVenereal DiseaseC.O.P.D
Please explain any condition(s) circled/checked
History of accidents, fractures, illness, operations
NoYes
If yes, which medications
NoYes
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: