Name: Philip Valdez

Department: Sales

Employee ID: 12345

Date of Hire: 05/15/2018

Position/Job Title: Sales Manager

Supervisor's Name: [Your Name]

Section 1: Health Questionnaire

Please answer the following questions honestly and to the best of your knowledge:

Do you have any existing medical conditions or chronic illnesses? If yes, please specify:

Diabetes Type 2

Are you currently taking any prescription medications or receiving ongoing medical treatment? If yes, please provide details:

Metformin for diabetes

Have you had any surgeries or hospitalizations in the past year? If yes, please provide details:

No

Do you smoke or use tobacco products?

Do you consume alcoholic beverages? If yes, please specify frequency and quantity:

Occasionally - 1-2 drinks per week

Do you engage in regular physical activity or exercise? If yes, please describe your exercise routine:

Regular walking and light jogging, 3 times a week

Do you experience high levels of stress at work or in your personal life? If yes, please describe the source of stress:

Occasional work-related stress due to tight project deadlines

Section 2: Biometric Measurements

Please provide the following biometric measurements:

Height: 5 ft. 10 in.

Weight: 175 lbs.

Blood Pressure (if available):

Systolic: 120 mm Hg

Diastolic: 80 mm Hg

Body Mass Index (BMI): Calculate using the following formula:

BMI = (Weight in pounds / (Height in inches x Height in inches)) x 703

Your BMI: 25.1

Fasting Blood Glucose Level (if available): 110 mg/dL

Total Cholesterol Level (if available): 190 mg/dL

HDL Cholesterol Level (if available): 45 mg/dL

LDL Cholesterol Level (if available): 130 mg/dL

Section 3: Health Risk Assessment

Please answer the following questions related to your lifestyle and health risks:

Are you currently experiencing any symptoms of illness or discomfort that you have not discussed with a healthcare professional? If yes, please describe:

No

Have you been vaccinated against common preventable diseases? If not, please specify which vaccines you have not received:

Up-to-date on all recommended vaccines

Are you aware of any allergies or sensitivities that may impact your health at work? If yes, please specify:

No

Section 4: Mental Health Assessment

Please answer the following questions related to your mental well-being:

Do you feel that you are experiencing excessive stress or anxiety that affects your ability to perform your job effectively? If yes, please describe:

Occasional work-related stress, but manageable

Have you sought or are you currently receiving mental health support or counseling? If yes, please provide details:

No

Section 5: Health and Wellness Programs

Please indicate your interest in the following health and wellness programs (if offered by the company):

●    Fitness Classes

●    Smoking Cessation Programs

●    Nutrition Counseling

●    Stress Management Workshops

         Employee Assistance Program (EAP)

Section 6: Employee Acknowledgment

I understand that the information provided in this Employee Health Review Form will be used for the purpose of promoting employee health and well-being. I acknowledge that my participation is voluntary, and the information I provide will be kept confidential.

Employee Signature: Philip Valdez

Date: 09/15/2023

HR/Healthcare Provider Use Only:

Reviewed by: Dr. Emily Anderson, MD

Date: 09/16/2023

Additional Notes:

Employee provided thorough and accurate information regarding their health status.

Blood pressure and cholesterol levels within acceptable ranges.

Employee's BMI indicates they are in the overweight range, suggesting a need for dietary and exercise counseling.

Recommendations/Referrals:

Dietary and Exercise Counseling: Recommend referring the employee to our company's nutritionist and fitness trainer to address BMI concerns and promote healthier lifestyle choices.