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Template: Medical Intake
Pre-Employment Health Questionnaire
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Collect relevant health information from potential employees before employment.
This is a preview of the template. Click here to use it.
Full Name
*
Date of Birth
*
Position Applied For
*
Have you ever had any of the following conditions?
Asthma
Diabetes
Heart Disease
High Blood Pressure
Seizures
Back Problems
Chronic Illness
Other (please specify)
If you selected 'Other', please specify
Do you currently take any prescribed medications?
*
Yes
No
If yes, please list your medications
Have you been hospitalized in the last 5 years?
*
Yes
No
If yes, please provide details
Do you have any known allergies (e.g., food, medication, environmental)?
Do you have any physical or mental conditions that could affect your ability to perform job-related tasks?
Yes
No
If yes, please describe the condition(s)
Additional Comments
*
I certify that the information provided is true and accurate to the best of my knowledge.
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