Health Questionnaire & Drug Use Info "*" indicates required fields To be completed after an employment offer is made and before the employee begins work. This medical information is being gathered in compliance with the Americans With Disabilities Ace (ADA) and will be maintained in a separate medical file as a confidential medical record, except that supervisors/managers may be informed about necessary work restrictions and accommodations; first-aid/safety personnel may be informed of any necessary information for emergency medical treatment; and the government may be provided with this information when enforcing the ADA. 42 USCA § 12112(d) (3) (West 2008) In addition, the employer reserves the right to use this information to assist in presenting a workers’ compensation claim for reimbursement under any Subsequent/Second Injury Trust Fund. 29 C.F.R § 1630.14(b) (West2008) Date* MM slash DD slash YYYY Employee Name* First Middle Last Hire Date* MM slash DD slash YYYY Social Security #* Date of Birth* MM slash DD slash YYYY Please check each of the following health conditions you have experienced.* Neck pain or discomfort of any kind? Back pain or discomfort of any kind? Hand or wrist pain or discomfort of any kind? Shoulder pain or discomfort of any kind? Ankle pain or discomfort of any kind? Knee pain of discomfort of any kind? Headaches? Epilepsy? Diabetes? Arthritis or similar degenerative joint disease? Amputated foot, leg, hand or arm? Loss of sight in one or both eyes or a partial loss of vision greater than 75% in both eyes? Polio or any continuing effects from such condition? Cerebral palsy, muscular dystrophy or multiple sclerosis? Parkinson’s disease? Heart or blood vessel disorders? Phlebitis or thrombosis (blood clots) Pulmonary embolism? Tuberculosis? Emphysema, asthma or any other breathing disorders? Hemophilia, sickle cell anemia or any other diagnosed blood disorders? Hypoglycemia or hyperglycemia (low or high blood sugar)? Chronic osteomyelitis (bone infection)? Ankyloses or fusion of any major joints? Ruptured, herniated, bulging or slipped disc of the neck or back? Loss of hearing? Any permanent condition which constitutes impairment to a hand, foot, leg or arm, or the body as a whole? Joint pain or discomfort of any kind? None If you have checked any of the foregoing conditions, please describe the nature of the condition.*Have you ever received medical care or surgery for any of the conditions listed above?* Yes No Please explain.*Have you ever been hospitalized for any of the conditions listed above?* Yes No Please explain.*Are you presently receiving care or have you received care during the past year for any of the conditions listed above?* Yes No Please explain.*Are you currently receiving treatment or have you ever received treatment for a medically diagnosed mental illness or disorder such as depression, manic depressive condition, anxiety, schizophrenia, or any similar or related condition?* Yes No Please explain.*Are you currently receiving treatment or have you ever received treatment for an alcohol or drug condition?* Yes No Please explain.*Do you have any physical condition which we should be aware of in the event of a medical emergency?* Yes No Please identify the condition, and if applicable, your treating physician.*Please list all prescribed medications you are currently taking.Drug Use InformationCheck all the medications, pills, drugs, or other substances you have used within the past 3 days. This information will be used to help interpret the results of your blood and /or urine test.* Acetaminophen Amphetamine Anti-Anxiety Medications Antidepressants Asthma, Lung Medications Blood Pressure Medications Codeine Demerol Dilaudid Heart Medication Methadone Muscle Relaxants Pentazocine Poppy Seeds Quinine Pills Tranquilizers Alcohol Antacids Anti-Convulsant Medications Antibiotics Barbiturates Cocaine Cold Remedies Diet Pills Diuretics Marijuana Morphine Pain Medication Sleeping Pills Phencyclidine Quaalude None Consent* I Agree to Sign Electronically.The above is a true testament of the medications or drugs in which I have used in the past 3 days. I understand that false or incomplete information is cause for disqualification or dismissal.*
