Employee Fitness Questionnaire

EMPLOYEE FITNESS QUESTIONNAIRE

Purpose: This Employee Fitness Questionnaire collects medical and functional information necessary to determine fitness for duty, workplace accommodations, and any restrictions relevant to the employee’s position. Responses will be maintained confidentially in the employee health record and used only for job-related determinations and lawful administration. Complete all sections fully and truthfully.

Personal Information

Date of Birth:   Gender:

Position Information

Proposed Start Date:   Salary/Rate: $

Employment Status:   Full-time   Part-time   Temporary/Seasonal

Employment History (Most Recent Employers)

Dates Employed: From to

Dates Employed: From to

Education

References (Professional)

Medical and Functional History

Do you currently have or have you ever had any of the following conditions? Check Yes for any that apply and provide details in the corresponding explanation field.

Heart disease or cardiac condition: Yes   Explain:

Hypertension (high blood pressure): Yes   Explain:

Diabetes: Yes   Explain:

Seizure disorder or fainting spells: Yes   Explain:

Respiratory or pulmonary disease (e.g., asthma): Yes   Explain:

Functional Abilities and Restrictions

Can you safely perform the essential physical requirements of the position as described by your manager?   Yes   No  If No, explain limitations:

Lifting capacity: Able to lift up to without assistance   If restricted, describe:

Able to stand continuously for hours   Able to walk

Ability to climb, balance, stoop, kneel, crouch, crawl: Yes   No   If No, explain:

Exposure limitations (e.g., heights, confined spaces, chemicals):

Provider Information (If Applicable)

Legal Notices, Disclosures, and Authorizations

Confidentiality: Medical information provided on this form will be kept confidential and maintained separately from general personnel files. Access will be limited to individuals with a legitimate need to know for fitness-for-duty assessments, safety determinations, or accommodation processing.

Americans with Disabilities Act (ADA): This employer complies with applicable disability laws. If you identify limitations that qualify as a disability under the ADA, the employer will engage in an interactive process to determine reasonable accommodation unless doing so would impose an undue hardship.

Authorization to Obtain Medical Information: I authorize my treating providers to release to the employer any medical information necessary to evaluate my fitness for duty, work restrictions, and reasonable accommodations. This authorization includes test results, diagnoses, functional assessments, and treatment summaries relevant to job performance and safety.

Authorization to Contact Previous Employers: I authorize the employer to contact prior employers listed for verification of employment history and duties. I understand such contact may be used for job placement decisions.

At-Will Employment & Equal Opportunity: Completion of this form does not constitute an employment contract. Employment, if offered, is at-will unless otherwise agreed in writing. The employer is an equal opportunity employer and will not discriminate on the basis of protected characteristics in hiring, promotion, or assignment of duties.

Applicant Certification and Consent

I certify that the information on this Employee Fitness Questionnaire is true, complete, and accurate to the best of my knowledge. I understand that failure to disclose material medical information or falsification of this form may result in denial of employment or discipline up to and including termination. I consent to any reasonable medical examinations, drug/alcohol testing, or functional capacity evaluations that the employer may require to determine fitness for duty. I understand a conditional offer of employment may be contingent upon medical clearance where permitted by law.

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