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.

Physical Limitations

None

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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