EMPLOYEE MEDICAL DISCLOSURE FORM
Employee Name:
*
Are you currently taking any medications that we need to be aware of?
Please Select
Yes, See below.
No, there are no concerns.
Are there any medical concerns that you would care to share?
Please Select
Yes, See below.
No, there are no concerns.
List any medication information that you would to share.
*
List any medical concerns that you would to share. (For examples, seizures, depression, pre-existing diagnosis that require routine medical care, etc.)
*
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