Employee Medical History Questionnaire

Please check in the appropriate space whether or not you currently have or previously have had the following medical conditions:
	Yes	No		Yes	No
Epilepsy			Dizziness
Diabetes			Nervous Breakdown
Heart Disease			Ionizing Radiation Injury
Arthritis			Compressed Air Sequelae
Amputated foot, leg arm or hand or loss of use thereof			Spinal Fusion or surgical removal of an intervertebral disc
Loss of sight, partial or total			Bronchitis
Double vision or blurred sight			Emphysema
Poliomyelitis			Asthma
Cerebral Palsy			Ruptured Intervertebral disc (disc in neck or back)
Multiple Sclerosis			Hodgkin's Disease
Parkinson's Disease			Mental Retardation
Stroke			Carpal Tunnel Syndrome
Tuberculosis			High Blood Pressure
Silicosis			Rotator Cuff Injury
Asbestosis			Knee Injury
Mental Disability			Neck Injury
Hemophilia			Back Injury
Osteomyelitis			Thoracic Outlet Syndrome
Head Injury			Reflex Sympathetic Dystrophy
Ankylosis of Joints			Muscle, Ligament or Tendon Injury
Hyperinsulism
Muscular Dystrophy
Arteriosclerosis
Thrombophlebitis
Varicose Veins
Heavy Metal Poisoning
Brain damage

If you have answered "yes" above, for each affirmative answer please provide the following information about any doctor, chiropractor, psychiatrist, psychologist or therapist who has treated you for the condition(s): (Please use the reverse of this form if necessary.)

Condition: ____________________________________________________________________________

Treating Physician's Name and Phone Number: ________________________________________________

____________________________________________________________________________________

 

Condition: ____________________________________________________________________________

Treating Physician's Name and Phone Number: ________________________________________________

____________________________________________________________________________________

Treating Physician's Address: ______________________________________________________________

Diagnosis: ____________________________________________________________________________

Dates of Treatment: _____________________________________________________________________

 

Condition: ____________________________________________________________________________

Treating Physician's Name and Phone Number: ________________________________________________

____________________________________________________________________________________

Treating Physician's Address: ______________________________________________________________

Diagnosis: ____________________________________________________________________________

Dates of Treatment: _____________________________________________________________________

 

Condition: ____________________________________________________________________________

Treating Physician's Name and Phone Number: ________________________________________________

____________________________________________________________________________________

Treating Physician's Address: ______________________________________________________________

Diagnosis: ____________________________________________________________________________

Dates of Treatment: _____________________________________________________________________

 

Have you ever had an injury, disability or illness that required you to miss time from work? Yes | No
If you check yes, please provide the following information:

Employer: ____________________________________________________________________________

Injury, Illness or disability: ________________________________________________________________

Time missed from work: __________________________________________________________________

Name of doctor who treated you: ___________________________________________________________

 

Did you receive workers' compensation benefits? Yes | No

Has condition fully healed? Yes | No

Any residual impairment or restrictions? Yes | No

Did you return to work? Yes | No

Have you ever been turned down for any employment; medical, health or life insurance; or military services because of your health or mental condition? Yes | No If "yes," please explain: ____________________________

_____________________________________________________________________________________

 

When did you last see a doctor? _____________________________________________________________

Name of doctor who treated you: ____________________________________________________________

Address: ______________________________________________________________________________

Condition treated: _______________________________________________________________________

 

Name of your family doctor: ________________________________________________________________

Address: _______________________________________________________________________________

 

Has a doctor ever restricted your activities? Yes | No

If yes, please provide the following information:

What type of restrictions were placed? _________________________________________________________

Are restrictions temporary or permanent? _______________________________________________________

Are you currently under these restrictions? _____________________________________________________

 

Are you presently taking any medication? Yes | No

If yes, please provide the following information:

Name of medication: _____________________________________________________________________

Medical condition being treated: _____________________________________________________________

Name of doctor who prescribed medication: _____________________________________________________

Address and Phone: _______________________________________________________________________

 

Have you ever had surgery to any part of your body? Yes | No

If yes, part of body operated on: ____________________________________________________________

Type of operation performed: _______________________________________________________________

Date of operation: _______________________________________________________________________

Name of hospital where operation was performed: _______________________________________________

Name of Physician who performed surgery: ____________________________________________________

Address and Phone: ______________________________________________________________________

 

Please list all known allergies:

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

 

Please list name and telephone number of person to contact in case of an emergency:

_____________________________________________________________________________________

 

WARNING: PURSUANT TO LSA-R.S. 23:1208.1, I UNDERSTAND THAT THE FAILURE TO ANSWER TRUTHFULLY ANY OF THE ABOVE QUESTIONS MAY RESULT IN FORFEITURE OF ANY RIGHT I OR MY DEPENDENTS MAY HAVE TO WORKER'S COMPENSATION BENEFITS, INCLUDING MEDICAL TREATMENT AND EXPENSES. I HAVE READ AND FULLY UNDERSTAND THE ABOVE.

Employee signature_____________________________________________ Date______________________