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Template: Medical Intake
Comprehensive Health History and Current Health Status Form
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Capture a detailed health history and current health status for new employees.
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Full Name
*
Date of Birth
*
Position/Job Title
*
Have you had any of the following medical conditions? (Check all that apply)
Heart Disease
High Blood Pressure
Diabetes
Asthma
Seizures
Allergies
Chronic Pain
Mental Health Conditions
Surgery History
Other (please specify)
If you selected 'Other', please specify
Are you currently taking any medications?
*
Yes
No
If yes, please list your medications
Do you have any known allergies? (e.g., food, medication, environmental)
*
Have you had any surgeries or hospitalizations in the past five years?
*
Yes
No
If yes, please provide details
Do you have any physical or mental conditions that may require workplace accommodations?
*
Yes
No
If yes, please describe the accommodations needed
Current Health Status (e.g., general well-being, current issues)
*
Do you exercise regularly?
Yes
No
If yes, describe the type and frequency of exercise
Do you smoke or use tobacco products?
Yes
No
Do you consume alcohol?
Yes
No
Additional Comments or Concerns
Signature of Employee
*
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