Pre-Employment Health History Update Form
Personal Information
Full Name
Date of Birth
Position Applied For
Contact Number
Email
Health History
Have you had, or do you currently have, any of the following? (Check all that apply):
Diabetes
Hypertension
Heart Disease
Asthma
Epilepsy
Allergies
Other
If "Other", please specify:
Have you been hospitalized or undergone surgery in the last 5 years?
Yes
No
If yes, provide details:
Are you currently taking any medications?
Yes
No
If yes, please list:
Do you have any allergies?
Yes
No
If yes, please specify:
Do you have any physical or mental condition that may require workplace accommodation?
Yes
No
If yes, please describe:
Declaration
I certify that the information provided above is true and complete to the best of my knowledge.
Signature
Date