Health Screening Statement HR
Company/Organization: [Your Company Name]
Date: [Month Day, Year]
Personal Information:
Full Name | [Your Name] |
Address | [Your Address] |
Date of Birth | [Month Day, Year] |
Contact Number | [Your Number] |
Email Address | [Your Email] |
Medical History:
Please provide details about any significant medical conditions, illnesses, or surgeries. Include the dates of these events if possible.
Medical Conditions | None |
Surgery History | Appendectomy in 2078 |
Chronic Illnesses | None |
Medications:
List any medications you are currently taking, including the name, dosage, and purpose.
Medication Name | Dosage | Purpose |
Ibuprofen | 200mg | Pain Relief |
| | |
Allergies:
Please disclose any allergies you are aware of, including food allergies, environmental allergies, or medication allergies.
Allergies | None |
Allergic Reactions | No known allergic reactions |
Physical Limitations:
If you have any physical limitations or disabilities that could impact your ability to perform essential job functions, please describe them here.
Immunization and Vaccination Records:
Certain roles or industries may require specific vaccinations or immunizations. Please provide information on relevant vaccinations you have received.
Name of Vaccine | Date of Vaccination | Remarks |
Influenza | September 2075 | |
COVID-19 (Pfizer) | May 2076 | |
Consent and Authorization:
I hereby consent to the collection and use of the above health information for employment-related purposes. I understand that this information will be treated with confidentiality and used in compliance with applicable laws and regulations.
Name and Signature: [Your Name] Date: [Month Day, Year]
Confidentiality and HIPAA Compliance:
Your health information will be kept confidential and in compliance with the Health Insurance Portability and Accountability Act (HIPAA) where applicable.
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