Post Offer Medical Questionnaire - REM Occupational Health & Wellness

Company

Job Title of Offered Position

Name

First

Last

Date of Birth

Phone

** Please note, you MUST provide a working telephone number as our medical provider may be contacting you to further review this medical questionnaire. Failure for you to provide a working phone number may result in delay of your hire and start date **

CONSENT

I understand that I have been requested to complete a Post Offer of Employment medical questionnaire and evaluation by my prospective employer. The purpose of this process is to determine if I am physically safe to perform the physical demands of job I have been offered and ensure no health or safety risks exist which might create a direct threat to my safety of that of others.

I acknowledge that the physical assessment done today by the medical provider is not intended to diagnose or treat any medical conditions and does not replace the medical care I receive from my other treating provider(s).

I certify that I have carefully read and completed the questions above, and I affirm that the answers provided above are accurate and true to the best of my knowledge. I understand that falsification or omission of any of the above answers, or failure to fully disclose any information, may be grounds for cancellation of my offer of employment, OR, if already employed, may be grounds for immediate termination of my employment, regardless of when the omission or failure of disclosure of information is discovered by

Initials

I understand that if there are safety concerns on the part of the company or medical provider who reviews this medical questionnaire, that the medical provider may request that I provide pertinent medical clearance(s) and/or medical records to determine safety in performing essential job functions/duties.
I also understand any information in this medical questionnaire is kept confidential and will only be disclosed to the extent of the law. I release and authorize (A – below) ‘s designated healthcare provider the personal medical information obtained in this medical questionnaire to (B – below) so that they can determine whether I am able to safely perform the essential functions of the job for which I have received a conditional offer of employment, with or without reasonable accommodation.

Signature

Date

Do you take any prescription or over-the-counter medications?

Yes

If yes, list below:

Have you ever had any surgeries?

Yes

If yes, list below:

Have you ever had or been treated for any of the following orthopedic conditions? If yes, provide dates.

Carpel Tunnel Syndrome

Yes

Date

Tendonitis

Yes

Date

Sciatica

Yes

Date

Herniated (bulging) Disc(s)

Yes

Date

Joint Injections

Yes

Date

Sprains/Strains

Yes

Date

Trigger Finger

Yes

Date

Bursitis

Yes

Date

Arthritis

Yes

Date

Other:

Date

Have you ever had a work-related injury(ies) or illness(es)?

Yes

If yes, list:

Have you ever been on or are you currently on disability of any kind, such as workman’s compensation, social security disability, etc?

Yes

Do you require any medical accommodations to perform your offered job here?

Yes

Medical accommodations means: a reasonable accommodation is a modification or adjustment to a job, the work environment, or the way things are usually done during the hiring process. These modifications enable an individual with a disability to have an equal opportunity not only to get a job, but successfully perform their job tasks to the same extent as people without disabilities.

If yes, please list below:

Do you have any physical or mental health restrictions to work or activities?

Yes

If you do not know what medical accommodations means, please ask. If yes, please list:

Post Offer of Employment Medical Questionnaire and Evaluation

CONSENT