Medical History Questionnaire

Transcription

1 Medical History Questionnaire Instructions Human Resources Instructions: 1. Complete Section 1 of Medical History Questionnaire; 2. Determine whether candidate must complete Section 2A only or Section 2A and 2B of Medical History Questionnaire and check the appropriate box in Section 2, Candidate Instructions ; 3. Provide candidate with Essential Functions Job Analysis (EFJA); briefly explain purpose of EFJA and associated pre-employment medical exam and respond to questions; and 4. Instruct candidate to complete the Medical History Questionnaire as directed and take to exam, along with a government-issued photo ID. Physician Instructions: 1. Review Questionnaire responses and use this information in conjunction with your physical examination of the candidate to determine the candidate s ability to assume the position sought with or without the need for work restrictions; 2. Complete the Physician s Findings Form; and 3. Findings ONLY to the City of Santa Monica, Attention: Human Resources; retain completed Medical History Questionnaire with Clinic s files. DO NOT SEND COMPLETED MEDICAL HISTORY QUESTIONNAIRE TO THE CITY OF SANTA MONICA Approved: March 2015

2 Section 1 Exam Information (Completed by Human Resources) Department: Division: Job Classification: Section 2 Candidate Medical History Information (Completed by Candidate) Candidate: Date of Birth: Sex: Male Female Address: City: Zip: Home Phone: Social Security #: XXX-XX- (Last 4 digits) Candidate Instructions: Human Resources staff will review with you the purpose of the Pre- Employment Exam and Medical History Questionnaire, identify which portions of the Questionnaire you must complete, and provide you with a copy of the Essential Functions Job Analysis (EFJA) to assist with completing the Questionnaire. The EFJA identifies the: 1) core purpose of the job you will be asked to perform; 2) the essential functions which are critical to successful performance of the job; 3) the work environment and conditions in which the job is performed; and 4) the skills and abilities you must possess to perform the essential functions. Please review the EFJA carefully, and follow the directions provided below: Complete the following portions of the Medical History Questionnaire as instructed by Human Resources: 2A ONLY Section 2A and 2B As you complete the Questionnaire, be as accurate as possible and do not leave any answers blank (use N/A if not applicable or don t know ); and After answering all required questions, execute the Candidate Certification on Page 5 of form and take completed Medical History Questionnaire with you to your exam appointment along with a government-issued photo ID. DO NOT provide this completed questionnaire to any City of Santa Monica personnel. Please Keep in Mind The information you provide in this Questionnaire is extremely important. It will be used by a physician to advise the City of your ability to perform the essential functions of the job safely and without endangering yourself or others. 1 P a g e

3 Section 2A 1. Are you taking any medications (prescription or non-prescription) which affect your balance, awareness, hearing, sight, or ability to drive, walk, stand, sit, lift, bend, or reach? Yes No If your answer is Yes, provide the following information below: a. Type of medication(s) b. Specific work limitation(s) 2. Have you undergone any operations, surgeries or hospitalizations that limit your current ability to perform the essential physical or mental functions of the position? Yes No If your answer is Yes, provide the following information below: a. Date of procedure/hospitalization_ b. Specific work limitation(s) 3. Has a physician restricted you from currently performing any physical or mental activities that are necessary to perform the essential job functions? Yes No Date Restriction Given Name of Physician Restriction 4. Do you require any work-related accommodations for mental or physical condition(s) that limit your current ability to perform the essential mental or physical functions of your job? These may include, but are not limited to the following: vision or hearing impairment, allergies, skin conditions, dizziness/fainting/loss of consciousness, working in elevated locations, convulsions/seizures/epilepsy, breathing problems, diabetes, headaches, musculoskeletal problems, psychological or emotional disorders, drug/alcohol treatment issues, etc. Yes No If your answer is Yes, provide the following information below: a. Specific work limitation(s): 2 P a g e

4 5. Do you currently experience any chronic pain or musculoskeletal problems which limit your ability to perform the essential functions of the job? These may include, but are not limited to the following: pain; tingling; numbness; limited motion; limitation in walking, standing, sitting, bending, lifting, and reaching. Yes No If your answer is Yes, circle below the body part(s) affected: Other Neck Shoulder Ankle Wrist Hand Back Hip Knee Elbow Foot Please indicate any work limitation(s) created by your condition: 6. Please identify on the diagrams below the areas you re currently experiencing pain, tingling, numbness or other problems identified in response to Question #5. Use xxx to show areas of pain; use ooo to show areas of tingling, numbness and other problems 3 P a g e

5 Section 2B *** STOP *** ****STOP**** Candidates should answer Section 2B questions only if instructed by Human Resources. If not instructed to do so, proceed to the Candidate Certification on Page 5. The following questions apply to candidates seeking jobs that require: (1) work in an environment where the employee is likely to come into contact with chemicals or substances (e.g. latex, radiation, lead, paints, glues, dust, etc.); and/or (2) use of personal protective gear or equipment. 1. Do you have an allergy and/or sensitivity (e.g. irritation to eyes or skin, difficulty breathing) to latex, chemicals or other substances that limits your current ability to perform the essential functions of your job? Yes No a. List specific work limitation(s) or describe how your allergies or sensitivities impact you in working: 2. From the list below, identify the personal protective gear/equipment that you believe you will be required to use in your job and describe any work restriction or limitation. Respirator? Yes No Hearing Protection? Yes No Gloves? Yes No Protective Clothing? Yes No Safety Glasses/Goggles? Yes No 4 P a g e

6 Section 2B -- Cont d Other Gear/Equipment? Yes No 3. Are you currently receiving medical treatment because of an exposure to a chemical or biological substance? Yes No If your answer is yes, provide the following information below: a) Chemical or biological substance(s) b) Specific work limitation(s) c) Type(s) of job accommodation(s) requested 4. Have you ever worked with any of the following? (Check all that apply) Asbestos Dust Latex Lead Noise Pesticides Radiation Silica Powder Solvents Substances which irritated your skin or eyes Substances that caused you breathing difficulties Other chemical/biological substances (specify): Candidate Certification: I understand that a physical examination is a part of the application process for employment with the City and that a hiring decision may be based on the results of the physical examination. I hereby certify that all of my statements and answers are true and complete to the best of my knowledge. I understand that any false or misleading information, or misstatement of material fact, may disqualify me from employment with the City of Santa Monica; or may result in my termination after being hired. Signature: Date: 5 P a g e

7 Section 3 -- Physician Exam (Completed by Physician Performing Exam) Physician Instructions: 1. Review Questionnaire responses and use this information in conjunction with your physical examination of the candidate to determine the candidate s ability to assume the position sought with or without the need for work restrictions; 2. Complete the Physician s Findings Form; and 3. Findings ONLY to the City of Santa Monica, Attention: Human Resources; retain completed Medical History Questionnaire with Clinic s files. Physician Signature: Date: Clinician Comments/Notes: _ DO NOT SEND COMPLETED MEDICAL HISTORY QUESTIONNAIRE TO THE CITY OF SANTA MONICA Medical Health History Questionnaire docx 6 P a g e