Free Employee Medical Form

Please fill out the form with your information below.
Name
Date of Birth
Gender
Male
Female
Job Title
Department
Do you have any of the following medical conditions?
Check all that apply and provide details where necessary.
Hypertension
Heart Disease
Epilepsy or Seizures
Chronic Pain or Arthritis
Mental Health Conditions
Do you have any physical limitations that may affect job performance?
If Yes, please specify:
Do you have any work-related medical restrictions?
If Yes, please specify:
Employee Acknowledgement
I certify that the information provided is true and correct to the best of my knowledge. I understand that this form will be used for workplace safety and medical compliance.
Name:
Date:
Thank you for your submission!
We appreciate you taking the time to submit.
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Ensure workplace health and safety with this Employee Medical Form Template from Template.net. Ideal for HR departments, occupational health offices, and corporate wellness programs, this form records employee medical history, current conditions, and fitness for work. Fully customizable in our AI Editor Tool, modify sections for allergies, medications, and emergency contacts.