Health Screening Statement HR
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.
