Employee Health History Form

EMPLOYEE HEALTH HISTORY FORM

Personal Information

Employee Name:

Date of Birth:    Employee ID:

Position Information

Reporting Manager:    Start Date:

Emergency Contact

Primary Care / Treating Provider

Date of Last Visit:

Medical History — Conditions (Check all that apply)

Diabetes    Hypertension    Heart disease

Asthma / COPD    Seizure disorder    Cancer

Depression / Anxiety    Musculoskeletal / Back problems    Neurological disorders

Immunocompromised    Vision / Hearing impairment    Other (describe below)

Medications, Allergies & Treatments

Work-Related Functional Limitations & Accommodations

Do you currently have any work restrictions or functional limitations?   Yes    No

Immunizations / Screening

COVID-19 vaccine    Influenza (seasonal)    Tdap

TB Test: Positive    Negative    Date of most recent TB test:

Lifestyle / Safety

Tobacco use: Never   Current   Former

Alcohol use: Yes    No    Recreational drug use: Yes    No

Mental Health

Are you currently receiving treatment for a mental health condition?   Yes    No

Employment History (Most recent two employers)

Dates Employed:    Reason for Leaving:

Dates Employed:    Reason for Leaving:

Education

Graduation Date:

References (Professional)

Legal Disclosures & Authorizations

At-Will Employment: I understand that, unless otherwise provided in a written agreement signed by an authorized representative, my employment is at-will and may be terminated by either the employer or me at any time, with or without cause or notice. I acknowledge that completion of this health history form is not a contract of employment.

Equal Opportunity: The employer is an equal opportunity employer. Medical information collected on this form will be used only for legitimate employment purposes, including fitness for duty determinations and accommodation assessment, and will be handled consistent with applicable privacy laws and employer policy.

Authorization to Release Medical Information: I authorize any treating physician, health care provider, clinic, or hospital to disclose to the employer or its designated representative any medical information necessary to evaluate my fitness for employment, need for reasonable accommodation, or work-related restrictions. This authorization is valid for the duration necessary to complete the employer's assessment but not longer than required by applicable law.

Consent to Examination: I consent to any job-related medical examination required by the employer to determine my ability to perform the essential functions of my position, with or without reasonable accommodation, and I consent to the release of the examination results to the employer for that purpose.

Confidentiality Acknowledgment: The employer will limit access to medical information to those with a legitimate business need to know. Information will not be released to unauthorized persons without my written consent except as required by law.

By checking the following box I acknowledge that I have read and understand the statements above and authorize the disclosures and examinations described.

I acknowledge and authorize the above disclosures and examinations.

Applicant Certification

I certify that the information provided on this form is true, accurate, and complete to the best of my knowledge. I understand that falsification, omission, or failure to disclose a medical condition or work restriction may result in disciplinary action, up to and including termination. I authorize the employer to contact my listed providers for verification of medical information where permitted by law.

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