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Employee Health Assessment

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Indicate illnesses experienced by you or family (Yes or No)
Kidney Disease
Heart Disease
Latex Allergy
High Blood Pressure
Mental Illness

TB Screen (History and PPD)(Yes or No)
Chest Pain
Lingering Cough
Loss of Energy
Unexplained Weight Loss in past year
Blood in Sputum
Increased Sweating at Night

Indicate any illness experienced since last assessment (Yes or No)
Migraine Headaches
Fainting or Dizziness
Weight Gain/Loss of 15+ lbs.
Change in Energy Level
Frequent Cough
Blood in Sputum
Shortness of Breath
Chest Pain/ Pressure in Chest
Swelling in Legs/Feet
Pain in calf when walking
Change in bowel habits
Back Pain
Pain when urinating or blood in urine
High Blood Pressure
Infectious Disease
Increased Thirst
Persistent Sores/ Lumps

Are you a smoker?
Do you drink alcoholic beverages?
Do you take antidepressants, stimulants, or narcotic drugs?
Do you take prescription medications?
I have carefully read and completed this form, and declare that I have no illness or injury, then listed above that will affect my performance while conducting my job’s responsibilities. I am not addicted to any stimulants, drugs, or narcotics, including anti-depressants, or any other substances that may alter my behavior, including alcohol.
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