Employee Health Screening Form
Please complete this health screening form to help us understand your current health status and history. Your responses will be kept confidential and are essential for providing appropriate health support at work.
Personal Information |
Employee Details |
Full Name: | [Name] |
Employee ID: | |
Department/Area: | |
Contact Number: | |
Email Address: | |
Emergency Contact |
Name: | [Name] |
Relationship: | |
Contact Number: | |
Health History |
Medical History |
Have you been diagnosed with any of the following conditions? (Please check all that apply) | |
Health History | |
Medical History | |
Have you been diagnosed with any of the following conditions? (Please check all that apply) | |
Family Health History | |
Do any of the following conditions exist in your immediate family? (Please check all that apply) | |
Lifestyle Information | |
Dietary Habits | |
How would you describe your diet? (Please select one) | |
Physical Activity | |
How often do you engage in physical exercise? | |
Substance Use | |
Do you use any of the following? (Please check all that apply) | |
Current Health Status |
Symptoms and Concerns |
Are you currently experiencing any health symptoms or concerns? Please describe. | |
Medications |
List any medications you are currently taking, including over-the-counter drugs: | |
Urgency and Consent and Privacy Statement
I, [Name], consent to this health screening and understand its purpose. I confirm that the information provided is accurate to the best of my knowledge. I acknowledge that my health information will be kept confidential and will only be used to support my health and wellness at work.
[Name]
[Month Day, Year]
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