Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Occupational Health History Form
Your information
Full Name *
Current Employer & Job Title
Employment History
Hazardous Substance Exposures
PPE Usage History
Work-Related Injuries
Workers' Compensation Claims
Additional details
Respiratory Surveillance Results
Audiometric Testing History
Ergonomic Risk Factors
Current Work Restrictions
Fitness-for-Duty Status
Relevant Medical Conditions
Patient Signature
Date
Occupational Health History Form template from formisoft.com. formisoft.com/intake-templates/occupational-health-history