- Today's Home Care, Inc.
- 2575 East 14 Street, Unit C1, Brooklyn, NY 11235
- 70-09 Austin Street, 2nd Floor, Forest Hills NY 11375
- Office Phone: 718-650-3358 | Fax: 855-259-2365
- www.TodaysHC.com | [email protected]
ANNUAL PHYSICAL ASSESSMENT
Employee Name: *
ID #: *
Date:
Employee Name:
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.
I understand that any falsification or misrepresentation of medical facts will be sufficient grounds for my release from employment.
Employee Signature: (Подпись): *
Within the past 12 months have you had:
CONDITION
YES
NO
CONDITION
YES
NO
Surgery
Digestive Problems
Fractures
Diabetes
Disabling Injury
Loss of Weight
Hernia
Arthritis
Chronic back pain/injury
Have you noticed lumps or nodules in your breast?
Fainting Spells
Problem with habituation or addiction to alcohol, depressants, stimulants, narcotics or other substances that may alter behavior
Seizures
Are you or have you been restricted in the kind or amount of work you do?
Mental Illness
Have you been treated for an infectious condition?
Chronic Coughing
Are you being treated for a medical condition?
Asthma-Allergies
The form was sent successfully.
An error occured.
[field id="EName"]
[field id="ID#"]
[field id="Date"]
[field id="ESig"]
[field id="SurYes"]
[field id="SurNo"]
[field id="DPYes"]
[field id="DPNo"]
[field id="FraYes"]
[field id="FraNo"]
[field id="DiaYes"]
[field id="DiaNo"]
[field id="DIYes"]
[field id="DINo"]
[field id="LWYes"]
[field id="LWNo"]
[field id="HerYes"]
[field id="HerNo"]
[field id="NodYes"]
[field id="NodNo"]
[field id="CBYes"]
[field id="CBNo"]
[field id="ArtYes"]
[field id="ArtNo"]
[field id="FSYes"]
[field id="FSNo"]
[field id="AddYes"]
[field id="AddNo"]
[field id="SeiYes"]
[field id="SeiNo"]
[field id="ResYes"]
[field id="ResNo"]
[field id="MIYes"]
[field id="MINo"]
[field id="InfYes"]
[field id="InfNo"]
[field id="CCYes"]
[field id="CCNo"]
[field id="MedYes"]
[field id="MedNo"]
[field id="AAYes"]
[field id="AANo"]
[field id="ExpYes"]
to Sheepshead Bay
to Forest Hills 71