Employee Health Questionnaire

June 13, 2011

Please complete this questionnaire. All the information provided by you will be kept confidential.

Name: _________________

Middle Name: ______________

Surname: __________________

Designation: _________________

Date of Birth: _________________

Address: ____________________

Telephone Number: ______________

Department: ____________________

Please tick on the appropriate option if you have any history of the below mentioned health conditions:

  1. Cardiovascular Disease:     Yes         No
  1. Diabetes:                             Yes        No
  1. Mental Disability:               Yes        No
  1. Alcoholism:                         Yes       No
  1. Allergies:                             Yes       No
  1. Physical disability:               Yes      No

Please answer the questions correctly:

Are you currently on any kind of medication? ___________________________

Did you ever have to undergo surgery? ___________________________

If yes, what kind to surgery was that? _________________________

Is there any health condition that affects your ability to work? ____________________

Do you have any hearing problem? _________________________________

Do you have any eye related problems? _________________________________

Do you wear spectacles? _____________________________________

Is there any family history of spondylitis? _______________________

Is there any family history of heart ailment? ________________________

I hereby declare that all the information provided by me in this questionnaire is true.

I understand that any distortion of fact can result in losing my job and lead to termination from my employment.

Employee’s Signature __________________________

Date __________________

Download Employee Health Questionnaire in Word Format

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