• Skip to primary navigation
  • Skip to main content
REM Occupational Health & Wellness

REM Occupational Health & Wellness

Leaders in Occupational Health & Wellness

  • Home
  • Services
  • About
  • Testimonials
  • Post Offer Medical Questionnaire
    • English
    • Español
  • Contact
  • Show Search
Hide Search

Post Offer Medical Questionnaire

Post Offer of Employment Medical Questionnaire and Evaluation 

Please note, only complete this form if you have been asked to by your company representative.  This online form and the information being transmitted in it is done so in a secure manner to keep your information safe.

To view this form in Spanish (Español), please click here.

Post Offer of Employment Medical Questionnaire
Name *
Name
First
Last

** 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
  • 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.

Do you take any prescription or over-the-counter medications? *
Have you ever had any surgeries? *

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

Carpel Tunnel Syndrome *
Tendonitis *
Sciatica *
Herniated (bulging) Disc(s) *
Joint Injections *
Sprains/Strains *
Trigger Finger *
Bursitis *
Arthritis *
Have you ever had a work-related injury(ies) or illness(es)? *
Have you ever been on or are you currently on disability of any kind, such as workman’s compensation, social security disability, etc? *
Do you require any medical accommodations to perform your offered job here? *
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.
Do you have any physical or mental health restrictions to work or activities? *

Contact us today to schedule your onsite visit!I'm Ready!

REM Occupational Health & Wellness

Copyright © 2023 • REM Occupational Health & Wellness. Big Bend, Wisconsin. All Rights Reserved.