MM slash DD slash YYYY
This annual physical assessment is not intended to be a complete physical examination, nor to replace medical care by your own physician. This is to certify, that o the best of my knowledge, there is no health impairment present that is of potential risk to me, patient, family, or other employees, or that may interfere with the performance of my duties. I certify that I am free from habitation or addiction to depressants, stimulants, narcotics, alcohol, or other drugs or substances which may alter my behavior. I understand that any falsification or misrepresentation of medical facts will be sufficient grounds for my release from employment.
Within the past 12 months have you had:

CONDITION

CONDITION

Surgery
Surgery
Digestive Problems
Digestive Problems
Fractures
Fractures
Diabetes
Digestive Problems
Disabling Injury
Disabling Injury
Loss of Weight
Loss of Weight
Hernia
Hernia
Arthritis
Arthritis
Chronic back pain/injury
Chronic back pain/injury
Have you noticed lumps or nodules in your breast?
Have you noticed lumps or nodules in your breast?
Fainting Spells
Fainting Spells
Problem with habituation or addiction to alcohol, depressants, stimulants, narcotics or other substances that may alter behavior
Problem with habituation or addiction to alcohol, depressants, stimulants, narcotics or other substances that may alter behavior
Seizures
Seizures
Have you been treated for an infectious condition?
Are you or have you been restricted in the kind or amount of work you do?
Mental Illness
Mental Illness
Are you or have you been restricted in the kind or amount of work you do?
Are you being treated for a medical condition?
Chronic Coughing
Chronic Coughing
Are you being treated for a medical condition?
Have you been treated for an infectious condition?
Asthma-Allergies
Asthma-Allergies
This field is for validation purposes and should be left unchanged.
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