Health History 2 Health History Form 2 Personal InformationToday's Date* MM slash DD slash YYYY Name* First Last SSN* Birth Date* Month Day Year Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Employment InfoEmployer of Hire* Job Title* Location* Medical HistoryWhat is Your Current Height?* What is Your Current Weight?* Answer yes/no to the following questions. Describe yes answers:Allergies/Asthma/Hay Fever?* Yes No Describe "Yes" Allergies/Asthma/Hay Fever AnswerDate of Allergies/Asthma/Hay Fever MM slash DD slash YYYY Diabetes?* Yes No Describe "Yes" Diabetes AnswerDate of Diabetes MM slash DD slash YYYY Heart Disease (heart attack or heart surgery)?* Yes No Describe "Yes" Heart Disease (heart attack or heart surgery) AnswerDate of Heart Disease MM slash DD slash YYYY History of a Stroke?* Yes No Describe "Yes" History of a Stroke AnswerDate of Stroke MM slash DD slash YYYY History of Cancer Diagnosis?* Yes No Describe "Yes" History of Cancer Diagnosis AnswerDate of Cancer Diagnosis MM slash DD slash YYYY Numbness of Hands/Feet?* Yes No Describe "Yes" Numbness of Hands/Feet AnswerDate of Numbness of Hands/Feet MM slash DD slash YYYY Back Pain, Injury or Surgery?* Yes No Describe "Yes" Back Pain, Injury or Surgery AnswerDate of Back Pain, Injury or Surgery MM slash DD slash YYYY Neck Pain, Injury or Surgery?* Yes No Describe "Yes" Neck Pain, Injury or Surgery AnswerDate of Neck Pain, Injury or Surgery MM slash DD slash YYYY Knee Pain, Injury or Surgery?* Yes No Describe "Yes" Knee Pain, Injury or Surgery AnswerDate of Knee Pain, Injury or Surgery MM slash DD slash YYYY Swollen Joints?* Yes No Describe "Yes" Swollen Joints AnswerDate of Swollen Joints MM slash DD slash YYYY Shoulder Dislocation or Pain?* Yes No Describe "Yes" Shoulder Dislocation or Pain AnswerDate of Shoulder Dislocation or Pain MM slash DD slash YYYY Carpal Tunnel/Tendonitis/Wrist or Elbows Pain?* Yes No Describe "Yes" Carpal Tunnel/Tendonitis/Wrist or Elbows Pain AnswerDate of Carpal Tunnel/Tendonitis/Wrist or Elbows Pain MM slash DD slash YYYY History of High Blood Pressure?* Yes No Describe "Yes" History of High Blood Pressure AnswerDate of History of High Blood Pressure MM slash DD slash YYYY Operations, Hospitalizations, Injuries or Treatment for Medical Problems in the Past Year?* Yes No Describe "Yes" Operations, Hospitalizations, Injuries or Treatment for Medical Problems in the Past Year AnswerDate of Operations, Hospitalizations, Injuries or Treatment for Medical Problems in the Past Year MM slash DD slash YYYY Vision Correction? Last Exam?* Yes No Describe "Yes" Vision Correction Last Exam AnswerDate of Vision Correction Last Exam MM slash DD slash YYYY Tetanus Shot?* Yes No Describe "Yes" Tetanus Shot AnswerDate of Last Tetanus Shot MM slash DD slash YYYY Do You Use Tobacco Products? What & How Much & for How Many Years?* Yes No Describe "Yes" Tobacco Products AnswerDate of Last Tobacco Product Use MM slash DD slash YYYY Are You Taking Any Prescription Medication? If Yes, Please List All Medication Currently Taken.* Yes No Describe "Yes" Prescription Medication AnswerDate of Last Prescription Medication Use MM slash DD slash YYYY SignatureI certify that all answers are correct to the best of my knowledge. I also understand that the job offer is contingent on the results of the medical screening.SignatureSignature Date MM slash DD slash YYYY
