Pre-Employment Medical Checklist
[YOUR COMPANY NAME]
[YOUR COMPANY ADDRESS]
[YOUR COMPANY EMAIL]
[YOUR COMPANY PHONE NUMBER]
Date: November 27, 2050
Employee Name: Porter Hoppe
Email: porter@you.mail
Health History
Have you ever been diagnosed with any chronic illnesses?
☐ Yes
☐ No
Are you currently taking any medication?
☐ Yes
☐ No
If yes, please list: ________________________________
Do you have any allergies?
☐ Yes
☐ No
If yes, please specify: _____________________________
Have you had any surgeries or hospitalizations in the past 5 years?
☐ Yes
☐ No
If yes, please provide details: _______________________
Physical Fitness Evaluation
Test Name | Result | Notes |
|---|
| Pass | Meets minimum requirement for the role. |
| Pass | No issues detected in auditory testing. |
| 120/80 mmHg | Normal blood pressure recorded. |
| Pass | Completed within required time frame. |
Job-Specific Assessments
Does this job require heavy lifting?
☐ Yes
☐ No
Are you comfortable with working in confined spaces?
☐ Yes
☐ No
Will your job involve operating machinery?
☐ Yes
☐ No
Have you undergone any fitness-for-duty tests before?
☐ Yes
☐ No
If yes, provide details: ____________________________
Medical Consent
I, Porter Hoppe, hereby consent to the pre-employment medical examination as part of the hiring process. I understand that the information gathered will be used solely for employment-related purposes.
Date: November 27, 2050
Next Steps
Once completed, please submit this form to [YOUR COMPANY EMAIL]. If you have any questions or need assistance, feel free to contact us at [YOUR COMPANY PHONE NUMBER].
Thank you for your cooperation, and we look forward to reviewing your medical assessment!
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