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: _______________________

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Physical Fitness Evaluation

Test Name	Result	Notes
Vision Test	Pass	Meets minimum requirement for the role.
Hearing Test	Pass	No issues detected in auditory testing.
Blood Pressure	120/80 mmHg	Normal blood pressure recorded.
Physical Endurance	Pass	Completed within required time frame.

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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: ____________________________

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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

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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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