3 Post Hire Health Questionnaire - Laurens County …

1 post HIRE Health Questionnaire Confidential: This medical Questionnaire will only be used in the event that you have an on the job accident to help determine eligibility for the Georgia subsequent injury trust fund. _____, _____ _____ _____/_____/_____ Last Name Fist Name Middle Social Security Number _____ Street Address City ST Zip _____/_____/_____ _____ _____ Date of Birth Drivers License # Position Answer yes or no to each and write

2 Any applicable information under comments for any yes answers Yes No Yes No 1. Heart Disease or Heart Attack 2. Rheumatic Fever 3. High Blood Pressure Medication 4. Varicose Veins or Leg Ulcers 5. Chest Pain 6. Chronic Cough 7. Tuberculosis 8. Allergies 9. Hay Fever or Asthma 10.

3 Skin Trouble 11. Reaction to Serum or Drug 12. Kidney or Bladder Trouble 13. Ulcers 14. Diabetes Insulin dependent 15. Cancer 16. Hearing Trouble 17. Ear Infection or Running Ear 18. Mastoid Operation 19. Frequent Headaches 20. Head Injury 21. Eye Injury Right Left 22. Dizziness or Fainting Spells 23. Convulsions or Epilepsy 24. Frequent Backaches 25. Arthritis or Rheumatism 26.

4 Amputation of any part of body 27. Trouble with Bones or Joints 28. Nervous Condition 29. Weakness of any part of body 30. Osteoporosis 31. Trouble with ankles, legs, knees COMMENTS:_____ 1. Do you have any disease or impairment not listed above? Yes No If yes, what: _____ 2. Have you ever been treated for back problems: Yes No If yes, what: _____ _____ 3. Do you have any weight lifting restrictions? Yes No If yes, what: _____ 4.

5 Have you ever had any surgery: Yes No List all surgeries below or on the back of this form: Surgery_____ When _____ Doctor _____ Surgery_____ When _____ Doctor _____ 5. Have you ever had a body part rupture: Yes No If yes, which part: _____ I certify that the above entries are true, complete and correct to the best of my knowledge and belief and are made in good faith. _____ _____/_____/_____ Employee Signature Date