Pre-Employment Risk Factor Assessment Form

Assess potential health risk factors for new employees before employment.

Full Name *

Date of Birth *

Position/Job Title *

Date of Assessment *

Do you have any chronic health conditions? (e.g., diabetes, heart disease, asthma) *

If yes, please specify

Do you have any known allergies? *

If yes, please list your allergies

Have you had any surgeries in the past 5 years? *

If yes, please provide details

Do you currently take any prescribed medication? *

If yes, please list your medications

Do you have any physical or mental conditions that may impact your job performance? *

If yes, please describe

Do you have a family history of any significant health conditions (e.g., heart disease, cancer)?

If yes, please specify

Additional comments or concerns

Signature of Employee *

Date of Submission *