Pre-Employment Medical History Form
Personal Information
Full Name
Date of Birth
Gender
Male
Female
Other
Position Applied
Phone
Email
Address
Medical History
Do you have any history of the following? (If yes, please specify)
Condition
Yes/No
Details
Allergies
Yes
No
Asthma
Yes
No
Diabetes
Yes
No
Epilepsy
Yes
No
Heart Problems
Yes
No
High Blood Pressure
Yes
No
Other (please specify)
Yes
No
Current Medications
List any medications you are currently taking:
Surgeries & Hospitalizations
Have you ever had any surgeries or been hospitalized? If yes, please provide details:
Lifestyle
Do you smoke?
Yes
No
Do you consume alcohol?
Yes
No
Additional Information
Is there any other health related information you wish to disclose?
Date
Signature