Medical Questionnaire

"*" indicates required fields

Name*

First Last

Date*

Date of Birth*

Social Security Number*

NOTICE TO OFFEREES: In compliance with the Americans with Disabilities Act of 2008 (ADA), you have received a conditional offer of employment. This medical history statement is required of all offerees. The answers to the medical history statement and any medical examination will be kept confidential and in separate files in compliance with the ADA requirements. The job offer, which you have received, is conditioned upon satisfactory completion and review of this medical questionnaire and any required medical examination or follow up. GINA DISCLOSURE: The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. “Genetic information” includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services. EMPLOYEE AFFIRMATION: I herewith affirm that the employer has made me an offer of employment, conditioned on, among other things, the satisfactory completion of this questionnaire. The purpose of this inquiry is as follows: (1) to determine whether I currently have the physical qualifications necessary to perform the essential functions of the job that has been offered; (2) to determine what accommodations, if any, may be necessary for me to perform the essential functions of the job; and (3) to determine whether I can perform the essential functions of the job without posing a significant direct threat to the health and safety of myself and others. This information will be kept strictly confidential in a separate medical file, apart from my personnel file. I hereby affirm that the questions in the medical questionnaire have not been asked of me by anyone with the employer until after I have signed this statement and been offered a conditional job. The conditional job duties have been adequately described to me, and I have had an opportunity to ask questions regarding the duties.*

I acknowledge that the employer has made me an offer of employment, conditioned on, among other things, the satisfactory completion of this questionnaire.

NOTICE TO OFFEREES: In compliance with the Americans with Disabilities Act of 2008 (ADA), you have received a conditional offer of employment. This medical history statement is required of all offerees. The answers to the medical history statement and any medical examination will be kept confidential and in separate files in compliance with the ADA requirements. The job offer, which you have received, is conditioned upon satisfactory completion and review of this medical questionnaire and any required medical examination or follow up.
GINA DISCLOSURE: The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. “Genetic information” includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.
EMPLOYEE AFFIRMATION: I herewith affirm that the employer has made me an offer of employment, conditioned on, among other things, the satisfactory completion of this questionnaire. The purpose of this inquiry is as follows: (1) to determine whether I currently have the physical qualifications necessary to perform the essential functions of the job that has been offered; (2) to determine what accommodations, if any, may be necessary for me to perform the essential functions of the job; and (3) to determine whether I can perform the essential functions of the job without posing a significant direct threat to the health and safety of myself and others. This information will be kept strictly confidential in a separate medical file, apart from my personnel file. I hereby affirm that the questions in the medical questionnaire have not been asked of me by anyone with the employer until after I have signed this statement and been offered a conditional job. The conditional job duties have been adequately described to me, and I have had an opportunity to ask questions regarding the duties.

Post- Offer Medical Questionnaire Continued - Part 1

Do you now have, or have you ever had, any of the following:

Asthma*

Migraine Headaches*

Heart Trouble*

Head Injury or Injuries*

Swelling of the Legs or Ankles*

Fainting Spells or Dizziness*

Epilepsy*

Joint Pain or Arthritis*

Sickle Cell Anemia*

Cancer*

Repetitive Motion Disorder*

Tendonitis*

Stiffness of Major Weight-bearing Joints*

Kidney Problems*

Diabetes*

Hay Fever*

Color Blindness*

Any Amputations (foot, leg, arm, or hand)*

Loss of Sight in One or Both Eyes*

Cerebral Palsy*

Parkinson's Disease*

Multiple Sclerosis*

Muscular Dystrophy*

Hemophilia*

Ruptured Disc*

If you reported "Yes" to any above conditions, please explain:

Post- Offer Medical Questionnaire Continued - Part 2

If you answer 'NO' to any question below, you are saying you have NOT experienced pain, discomfort or injury to that particular body part and have NOT sought treatment from a medical professional.

Do you have partial loss of hearing?*

Do you need glasses to read or for driving/operating a car or machinery?*

Any wrist, arm, or elbow problems including Carpal Tunnel Syndrom?*

Any broken bones?*

High blood pressure?*

Any serious injury?*

Any hernia or rupture?*

Any neck pain and/or neck problems?*

Any back pain or injuries?*

Any surgeries?*

Partial loss of uncorrected vision of more than 75% bilaterally?*

Psychoneurotic Disability following confinement for treatment in a recognized medical or mental institution for a period in excess of six months?*

Have you participated in taking illegal drugs in the past 6 months?*

Do you have any conditions or have you sustained any injury that would have an effect on your capacity to perform the duties of this position without reasonable accommodations?*

Have you ever been treated for back pain?*

Have you ever been treated for neck pain?*

Have you ever been treated for hand pain?*

Have you ever been treated for foot and/or ankle pain?*

Have you ever been treated for knee pain?*

Inability to perform certain motions?*

Inability to assume certain positions?*

If you reported "Yes" to any above conditions, please explain (including dates, body parts and treating physicians):

Post- Offer Medical Questionnaire Continued - Part 3

Have you ever been forced to give up a job for health reasons?*

Have you ever been hurt on the job or filed a workers’ compensation claim in the past?*

Has a doctor given you an impairment rating?*

If so, please provide the reason and the percentage of impairment. If you have not been given an impairment rating, state “none.”

Are you taking any prescribed drugs that would interfere with your job performance?*

If yes, please list the medications. If you are not taking any medications, state “none.”

How many lbs. can you lift comfortably without help?*

Electronic Signature*

Full Name

Post- Offer Medical Questionnaire Continued - Part 1

Post- Offer Medical Questionnaire Continued - Part 2

Post- Offer Medical Questionnaire Continued - Part 3

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Phone: 678.714.7637

Fax: 678.714.7640

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