In Family Hands
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MO w-4
Federal w-4
Direct Deposit
Contact
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Home
About Us
Vision
Mission
Services
Healthy Children & Youth Program
Veteran Assistance Program
Consumer-Directed Services
Non-Medical Transportation
In-Home Health
Managed Care
Amazing Times: Adult Meeting Place
Forms & Docs
Authorization for Release of E.I.N. Number
Background Consent Application
CDS Timesheet
Employee Emergency & Backup Plan
Employee Health Questionnaire
Hours of Availability
In-Home Health Weekly Timecard
Job Application
Nurse Visit Form
Nurse Visit Variation Form
Patient Referral
Change of Address
Payroll Information
MO w-4
Federal w-4
Direct Deposit
Contact
Privacy Policy
Employee Health Questionnaire
Home
Employee Health Questionnaire
First Name
Last Name
Post Applied for
Please state your number of days' sickness absence from work in the last 12 months
Question
Answer (please circle answer)
Do you have any health/medical problems or physical limitations which might affect your ability to undertake this job (e.g. for jobs involving manual handling - bending down, pushing/pulling etc or any problems with backache or neck ache?
Yes
No
Have you ever had any health/medical problems, tuberculosis or other chest problems?
Yes
No
Are you having, or waiting for, medical treatment or investigations of any kind or on long term or regular prescribed medication, Have you ever had any alcohol or drug problems? (Excluding contraceptive pills)?
Yes
No
Do you now, or have you ever suffered from:
1. Eye disease or visual problems including impaired colour vision?
Yes
No
2. Disabling headaches or migraine?
Yes
No
3. Ear disease or hearing problems? Do you wear a hearing aid?
Yes
No
4. Stomach or bowel problems (e.g. diarrhea or or indigestion)
Yes
No
5. Jaundice or Hepatitis or other liver problems?
Yes
No
6. Hernia (rupture)?
Yes
No
7. Heart disease, high/low blood pressure or strokes?
Yes
No
8. Epilepsy, fainting, dizziness or loss of consciousness?
Yes
No
9. Any nervous system disorder (such as Multiple Sclerosis or Parkinson's disease)?
Yes
No
10. Any serious head injury with or without skull fracture?
Yes
No
11. Any skin problems (e.g. eczema, dermatitis) or recurrent infections?
Yes
No
12. Allergies (to drug or any other substance) or hay fever?
Yes
No
13. Any problems raising arms above shoulder height?
Yes
No
14. Any problems with back ache or neck ache?
Yes
No
15. Any time off work for backache or neck ache or aches/pains in other joints?
Yes
No
16. Any problems with any other joints or muscles e.g. wrists, hands, ankles, feet or weak thighs?
Yes
No
17. Any bone fracture, joint dislocation, or any surgery to muscles, joints or spine? Includes any artificial
joints or metal plates.
Yes
No
DECLARATION BY APPLICANT
I certify that to the best of my knowledge and belief the above answers are true and complete. I understand that now and, if employed by the In Family Hands, in the future I have a duty to report any health condition or medication which could affect safety, concentration or performance at work.
Please complete and return to the Recruiting Manager.
© 2017 In Family Hands Care. All rights reserved.
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