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Template: Medical Intake
Pre-Employment Risk Factor Assessment Form
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Assess potential health risk factors for new employees before employment.
This is a preview of the template. Click here to use it.
Full Name
*
Date of Birth
*
Position/Job Title
*
Date of Assessment
*
Do you have any chronic health conditions? (e.g., diabetes, heart disease, asthma)
*
Yes
No
If yes, please specify
Do you have any known allergies?
*
Yes
No
If yes, please list your allergies
Have you had any surgeries in the past 5 years?
*
Yes
No
If yes, please provide details
Do you currently take any prescribed medication?
*
Yes
No
If yes, please list your medications
Do you have any physical or mental conditions that may impact your job performance?
*
Yes
No
If yes, please describe
Do you have a family history of any significant health conditions (e.g., heart disease, cancer)?
Yes
No
If yes, please specify
Additional comments or concerns
Signature of Employee
*
Sign Here
Date of Submission
*
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