Blank Health Checklist for Employees
Employee Information
Company Information
Company Name:
Company Address:
Contact Email:
Contact Number:
Section 1: Personal Health Information
Date of Birth:
Known Allergies:
Chronic Conditions:
Section 2: Recent Health Check-Ups
Type of Test | Date of Last Test | Results (if applicable) |
|---|
Vision Test | | |
Hearing Test | | |
Blood Pressure Check | | |
Section 3: Health Declarations
In the last 14 days, have you experienced the following?
Section 4: Workplace Ergonomics Checklist
Ergonomic Item | Status | Notes |
|---|
Desk and Chair Setup | Comfortable? | |
Computer Screen Height | Adjusted Properly? | |
Breaks Taken Every Hour | | |
Section 5: Emergency Contact Information
Name:
Phone Number:
Relationship:
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!
Checklist Templates @ Template.net
