Annual Health Assessment Annual Health Assessment "*" indicates required fields Employee Name*Last 4 of SS#*Phone*Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Have you had or do you have any of the following conditions/symptoms?Allergies* Yes No Arthritis* Yes No Seizures* Yes No Diabetes* Yes No Heart Trouble* Yes No Exposure to Hepatitis* Yes No High Blood Pressure* Yes No Surgery within Past Year* Yes No Back Trouble* Yes No Have you had ANY immunizations, such as flu or tetanus shots, in the past year?* Yes No Please enter the date and type of immunizationName of a physician you would like us to contact in the event of any emergency or illness:Name*Phone*Do you have any health impairment which is of potential risk to the patient, or which might interfere with the performance of your duties, including the habituation or addiction to depressants, stimulants, narcotics, alcohol, ¿or other drugs which may alter your behavior?* Yes No Please explain the impairmentWhat is your current weight?*What is your current height?*Are you currently taking medication prescribed by a physician?* Yes No What medication and for what reasonCertification I certify that the information I have provided on this health assessment is true to the best of my knowledge. I understand that this assessment is not for diagnosis or treatment purposes, nor does it replace my physician’s medical examination.Signature*Date* MM slash DD slash YYYY