Pre-Employment Health Questionnaire

Collect relevant health information from potential employees before employment.

Full Name *

Date of Birth *

Position Applied For *

If you selected 'Other', please specify

Do you currently take any prescribed medications? *

If yes, please list your medications

Have you been hospitalized in the last 5 years? *

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?

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.