MEDICAL EVALUATION QUESTIONNAIRE THIS QUESTIONNAIRE WILL ONLY BE SEEN BY MEDICAL PERSONNEL. IT IS HIPAA PROTECTED. Step 1 of 12 8% The information contained in this transmission is privileged and confidential and/or protected health information (PHI) and may be subject to protection under the law, including the Health Insurance Portability and Accountability Act of 1996, as amended (HIPAA). This transmission is intended for the sole use of the individual or entity to whom it is addressed.Name* First Middle Initial Last Suffix Today's Date* MM slash DD slash YYYY Last 4 Digits of your Social Security Number* Date of Birth* MM slash DD slash YYYY Age*Height* Weight* Email* Gender* Male Female Primary Phone #*Secondary Phone #Job Title* HiddenCompany*——–Company* Have you served in the military?* Yes No Which branch?* Are you being treated by the veterans administration (VA) for any conditions?* Yes No If yes, what condition?* Section 21. Do you currently smoke tobacco, or have you smoked tobacco in the last month?* Yes No How many packs daily?* How many years have you smoked?* 2. Have you EVER HAD an Allergic reaction that caused shortness of breath?* Yes No When?* Did you seek medical care?* 3. Have you EVER HAD an Allergic/Anaphylactic reaction to insect stings (bees/wasps, etc.) that require treatment with EpiPen or treatment from an ER/ doctor?* Yes No Were you transported to a hospital by ambulance?* Yes No Please explain When and Where:*4. Have you ever been hospitalized for a reaction to Insect/bee/wasp stings?* Yes No When?* Where were you hospitalized?* 5. Do you have allergies to anything else?* Yes No Please list:* Section 3Have you EVER HAD any of the following pulmonary or lung issues?6. Chronic Bronchitis* Yes No When were you diagnosed?* Are you still receiving treatment?* 7. Asthma* Yes No When were you diagnosed?* Are you still receiving treatment?* 8. Pneumonia* Yes No When were you diagnosed?* Are you still receiving treatment?* 9. Emphysema* Yes No When were you diagnosed?* Are you still receiving treatment?* 10. Broken Ribs* Yes No When were you diagnosed?* Are you still receiving treatment?* 11. Tuberculosis* Yes No When were you diagnosed?* Are you still receiving treatment?* 12. Lung Cancer* Yes No When were you diagnosed?* Are you still receiving treatment?* 13. Pneumothorax* Yes No When were you diagnosed?* Are you still receiving treatment?* 14. Any chest injuries or surgeries* Yes No Please explain:*15. Any other lung problems you have been told about* Yes No Please explain:* Section 4Do you CURRENTLY have any of the following symptoms of pulmonary or lung illness?16. Shortness of breath* Yes No When did this start?* Did you receive medical treatment?* 17. Shortness of breath when walking fast on level ground or walking up a slight hill or incline* Yes No When did this start?* Did you receive medical treatment?* 18. Shortness of breath with exertion (1 flight of stairs)* Yes No When did this start?* Did you receive medical treatment?* 19. Have to stop for breath when walking at your own pace on level ground* Yes No When did this start?* Did you receive medical treatment?* 20. Shortness of breath when washing or dressing yourself* Yes No When did this start?* Did you receive medical treatment?* 21. Shortness of breath that interferes with your job* Yes No When did this start?* Did you receive medical treatment?* 22. Coughing that produces phlegm (thick sputum)* Yes No When did this start?* Did you receive medical treatment?* 23. Coughing that wakes you early in the morning* Yes No When did this start?* Did you receive medical treatment?* 24. Coughing that occurs mostly when you are laying down* Yes No When did this start?* Did you receive medical treatment?* 25. Coughing up blood* Yes No When did this start?* Did you receive medical treatment?* 26. Wheezing* Yes No When did this start?* Did you receive medical treatment?* 27. Wheezing that interferes with your job* Yes No When did this start?* Did you receive medical treatment?* 28. Chest pain when you breathe deeply* Yes No When did this start?* Did you receive medical treatment?* 29. Any other symptoms that you think may be related to lung problems* Yes No Please list:* Section 5Have you EVER HAD any of the following cardiovascular or heart problems?30. Heart Attack* Yes No When?* Are you currently receiving treatment?* 31. Stroke* Yes No When?* Are you currently receiving treatment?* 32. Chest Pains/Pressure* Yes No When?* Are you currently receiving treatment?* 33. Heart Failure* Yes No When?* Are you currently receiving treatment?* 34. High Blood Pressure* Yes No When?* Are you currently receiving treatment?* 35. Swelling of your legs and feet* Yes No When?* Are you currently receiving treatment?* 36. Heart Arrhythmia (irregular heart beat)(A-Fib)* Yes No When?* Are you currently receiving treatment?* 37. Any other heart problem that you have been told about* Yes No Please explain:* Section 6Have you EVER HAD any of the following cardiovascular or heart symptoms?38. Frequent pain or tightness in the chest* Yes No When?* Are you currently receiving treatment?* 39. Pain or tightness in your chest during physical activity* Yes No When?* Are you currently receiving treatment?* 40. In the past two years, have you noticed your heart skipping or missing a beat* Yes No Please explain:*41. Any symptoms that you think may be related to heart or circulation problems* Yes No Please explain:* Section 7Have you EVER HAD any of the following problems?42. Eye irritation* Yes No When?* Are you currently receiving treatment?* 43. Skin allergies or rashes* Yes No When?* Are you currently receiving treatment?* 44. Anxiety* Yes No When?* Are you currently receiving treatment?* 45. General weakness or fatigue* Yes No When?* Are you currently receiving treatment?* 46. Any other problem that might interfere with performance of duties requiring heavy exertion* Yes No Please explain:* Section 847. Have you EVER LOST vision in either eye, temporarily or permanently Yes No Temporary or Permanent* Temporary Permanent When did this occur?* Do you still have difficulty with your vision?* Do you CURRENTLY have any of the following vision problems?48. Wear contact lenses Yes No 49. Wear or have glasses to wear Yes No 50. Color blind Yes No 51. Any other eye or vision problems* Yes No Please explain:*52. Have you EVER HAD an injury to your ears, including a ruptured/perforated eardrum?* Yes No When did it occur?* Did you seek medical attention?* 53. Difficulty hearing* Yes No 54. Do you wear a hearing aid?* Yes No In which ear?* Right Left Both 55. Any other hearing or ear problem* Yes No Please explain:* Section 956. Have you EVER HAD a back injury?* Yes No Was it work related? Yes No When did it occur?* 57. Are you currently having problems with your back?* Yes No When did it start?* Are you seeking medical care?* Do you CURRENTLY have any of the following musculoskeletal problems?58. Weakness in any of your arms, hands, legs or feet* Yes No When did it start?* Are you currently seeking medical care?* 59. Back pain* Yes No Please describe:* Chronic Comes and goes With activity When did it start?* Are you currently seeking medical care?* 60. Difficulty fully moving your arms or legs (Range of motion)* Yes No When did it start?* Are you currently seeking medical care?* 61. Pain or stiffness when you lean forward or backward at the waist* Yes No When did it start?* Are you currently seeking medical care?* 62. Difficulty fully moving your head up or down, or side to side* Yes No When did it start?* Are you currently seeking medical care?* 63. Difficulty bending your knees* Yes No When did it start?* Are you currently seeking medical care?* 64. Difficulty squatting to the ground* Yes No When did it start?* Are you currently seeking medical care?* 65. Difficulty climbing a flight of stairs or a ladder carrying more than 25 lbs.* Yes No When did it start?* Are you currently seeking medical care?* 66. Any other muscle/skeletal problem that interferes with performing the duties of the job* Yes No Please explain:* Section 10Have you EVER BEEN treated for or consulted a healthcare provider for any of the following?67. Diabetes, elevated or low blood sugar* Yes No When?* Are you currently seeking medical care?* 68. Seizures or epilepsy* Yes No When?* Are you currently seeking medical care?* 69. Dizziness, balance issues, fainting* Yes No When?* Are you currently seeking medical care?* 70. Fear of heights* Yes No When?* Are you currently seeking medical care?* 71. Heat intolerance* Yes No When?* Are you currently seeking medical care?* 72. Treated on the job for heat related issues* Yes No When?* Are you currently seeking medical care?* 73. Loss of consciousness from Head Injury* Yes No When?* Are you currently seeking medical care?* Section 1174. Have you EVER HAD ANY surgeries? (I.E., Neck, back, heart, lungs, abdomen, etc.)* Yes No Surgery* Year surgery was performed* Surgery Year surgery was performed Surgery Year surgery was performed Surgery Year surgery was performed Surgery Year surgery was performed Surgery Year surgery was performed 75. Are you taking ANY medications for ANY reason (including over-the-counter medications)?* Yes No Medication* For what condition* Medication For what condition Medication For what condition Medication For what condition Medication For what condition Medication For what condition Medication For what condition Medication For what condition Medication For what condition Medication For what condition 76. Do you have a Primary Care Provider?* Yes No Are you seeing your Primary Care Provider on a routine basis?* Yes No Provider's Name* Provider's Location* What are you being treated for by your Primary Care Provider?*77. Have you ever had an occupational or work related injury?* Yes No When?* What happened?* What company?* Section 12Statement of Agreement* I understand that this information is required as part of the post-employment offer, pre-employment evaluation and that the offer of employment is conditioned on the results of this evaluation. By signing this form, I agree to the release of this information for the limited purpose of determining whether I can perform the essential functions of the position for which I have received an offer of employment. I certify that the answers on this form are true and understand that a false statement or omission may constitute grounds for a withdrawal of an employment offer or dismissal from employment. Type your name: By typing my name in this box, I am digitally signing my name and certifying that this information is accurate and truthful to the best of my knowledge.
