Blank Health Checklist for Employees

Employee Information

• Name:                               

• Email:                               

• Phone:                               

Company Information

• Company Name:                               

• Company Address:                               

• Contact Email:                               

• Contact Number:                               

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Section 1: Personal Health Information

1. Date of Birth:                               

2. Known Allergies:                               

3. Chronic Conditions:                               

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Section 2: Recent Health Check-Ups

Type of Test	Date of Last Test	Results (if applicable)
Vision Test		Normal Requires Follow-Up
Hearing Test		Normal Requires Follow-Up
Blood Pressure Check		Normal Requires Follow-Up

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Section 3: Health Declarations

In the last 14 days, have you experienced the following?

• Fever or chills

• Persistent cough

• Shortness of breath

• Contact with a confirmed contagious disease

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Section 4: Workplace Ergonomics Checklist

Ergonomic Item	Status	Notes
Desk and Chair Setup	Comfortable? Yes No
Computer Screen Height	Adjusted Properly? Yes No
Breaks Taken Every Hour	Yes No

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Section 5: Emergency Contact Information

• Name:                               

• Phone Number:                               

• Relationship:                               

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Please complete this checklist and submit it to                                by                               . For questions, contact us at                               .

By maintaining these health checklists, we ensure a safer and healthier workplace for everyone!

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