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TEAMFORCE Medical Questionnaire
Warning: Do not attempt to attend site if you are under the influence of Drugs or Alcohol.
Name
*
First Name
Last Name
Phone Number?
*
1. I agree not to consume alcohol 12 hours before the shift starts?
*
Yes
No
2. I Agree to abide with the TEAMFORCE D & A Policy. (Details presented upon form submission.)
*
Yes
No
3. You agree, you will not be under the influence of drugs, inhalants & other forms of substance abuse or usage at any time!
*
Yes
No
4. Have you had an Operation?
*
Yes
No
5. Have you been seriously injured in the past?
*
Yes
No
6. Have you ever had a serious head injury?
*
Yes
No
7. Received any in-paitent treatment for a physical or mental condition?
*
Yes
No
8. Been refused or dismissed from employment for health reasons?
*
Yes
No
9. Do you have High Blood Pressure?
*
Yes
No
10. Do you have Diabetes needing Insulin?
*
Yes
No
11. Do you suffer from Epilepsy or fits?
*
Yes
No
12. Have you ever had blackouts, recurrent dizziness or any condition, which may cause sudden collapse or incapacity?
*
Yes
No
13. Do you get discomfort or pain in the chest or shortness of breath on exercise? E.g. climbing a single flight of stairs
*
Yes
No
14. Do you have difficulty in moving rapidly over short distances, including on slopes, steps or rough ground?
*
Yes
No
15. Would you have difficulty in looking over either shoulder or any existing back problems?
*
Yes
No
16. Do you have difficulty with your eyesight?
*
Yes
No
17. Do you wear glasses for normal vision?
*
Yes
No
18. Do you wear contact lenses?
*
Yes
No
19. Do you have any difficulty with your hearing?
*
Yes
No
20. Have you used, or abused, drugs within the last 12 months?
*
Yes
No
21. Have you had any alcohol-related illness during the last 12 months?
*
Yes
No
22. Have you suffered from HAVS or experienced Vibration White Finger?
*
Yes
No
Please provide details of any other relevant health conditions that may affect your work?
23. Are you taking prescribed medication?
*
Yes
No
If so please give details of the reason for taking medication?
If you have answered yes to any of the above questions, please provide further details.
I grant TEAMFORCE rights to use the above details for current and future employment purposes.
*
Yes
no
Send to TEAMFORCE!
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