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Post Hire Medical Question Form

This Home Health Agency is committed to encouraging the employment of physically disabled persons, but it also wants to protect its rights to seek reimbursement from the Special Disability Trust Fund if an employee's pre-existing condition contributes to a subsequent injury by that employee in the course of employment.

Your answers to this Questionnaire will not be used as the bases for deciding whether to employ you and your response to this questionnaire will be considered and treated as a confidential medical record which will not be included in your personnel file.

Warning! This Home Health Agency, and its insurance carrier intend to rely upon the information provided by you in this Questionnaire. It is your obligation to provide truthful and complete information in response to the questions presented below.

If it is later determined that you gave an intentional false response, you may be disqualified from receiving workers' compensation benefits. In addition, you may be subject to termination of employment if it is later determined that you deliberately falsified your responses to this Questionnaire.

INSTRUCTIONS: Answer YES or NO to the following questions. If your answer is YES, list the approximate date of injury or treatment.

1. Have you ever had a back injury?(Required)
26. Do you have or have you ever had hyperinsulinism?(Required)
2. Have you ever had a hematite intervertebral disc in your back?(Required)
27. Do you have or have you ever had chronic osteomyelitis?(Required)
3. Have you ever had a back surgery for a removal of a disc?(Required)
28. Do you have or have you ever had thrombophlebitis?(Required)
4. Have you ever had a neck injury?(Required)
29. Do you have or have you ever had a total dizziness?(Required)
5. Have you ever had a hematite disc in your neck?(Required)
30. Do you have or have you ever had a magmatic fever?(Required)
6. Have you ever had a neck surgery for removal of a disc?(Required)
31. Do you have or have you ever had a varicose veins or your leg ulcer?(Required)
7. Have you ever had a knee injury?(Required)
32. Do you have or have you ever had tuberculosis?(Required)
8. Have you ever had a surgery on either of your knees?(Required)
33. Do you have or have you ever had allergies or asthma?(Required)
9. Have you ever had a shoulder injury?(Required)
34. Do you have or have you ever had skin trouble?(Required)
10. Have you ever had a surgery on either of your shoulders?(Required)
35. Do you have or have you ever had reactions to serum or drugs?(Required)
11. Have you ever had an elbow injury?(Required)
36. Do you have or have you ever had kidney trouble?(Required)
12. Do you have or have you ever had an amputation of your foot, leg, arm or hand?(Required)
37. Do you have or have you ever had muscular dystrophy?(Required)
13. Do you have or have you ever had epilepsy?(Required)
38. Do you have or have you ever had ulcers?(Required)
14. Do you have or have you ever had diabetes?(Required)
39. Do you have or have you ever had a head injury?(Required)
15. Do you have or have you ever had cardiac disease (heart trouble)?(Required)
40. Do you have or have you ever had a mental retardation?(Required)
16. Do you have or have you ever had Marie-Strumpell disease?(Required)
41. Do you have or have you ever had cancer?(Required)
17. Do you have or have you ever had total loss of sight of one or both eyes or a partial loss of corrected vision of more than 75% bilaterally?(Required)
42. Do you have or have you ever had any permanent physical condition which constitutes a 20% impairment of a member of the body as a whole?(Required)
18. Do you have or have you ever had a cerebral disability from poliomyelitis?(Required)
43. Are you new or have you ever been obese (30% over normal body weight)?(Required)
19. Do you have or have you ever had a cerebral palsy?(Required)
44. Do you have or have you ever had arthritis or rheumatism?(Required)
20. Do you have or have you ever had multiple sclerosis?(Required)
45. Have you ever been treated/advised to seek treatment for alcoholism?(Required)
21. Do you have or have you ever had Parkinson's disease?(Required)
46. Have you ever had a hernia? If the answer is yes, where is the location of the body?(Required)
22. Do you have or have you ever had vascular disorder?(Required)
47. Have you ever been treated for substance abuse or addiction?(Required)
23. Have you ever had psychoneurotic disability following treatment in a recognized Medical or mental institution, in excess of 6 months?(Required)
48. Have you ever had any injury, surgery, or disability which has not been described in the questions above? (If so, state in detail the nature of the injury, surgery or disability).(Required)
24. Do you have or have you ever had hemophilia?(Required)
49. Do you have or have you ever had a high blood pressure?(Required)
25. Do you have or have you ever had ankylosis of a major weight-bearing joint?(Required)
All statements and information given in this application are true, to the best of my knowledge and belief.
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