WellSpan Employee Health Service - New Hire Health Screening

First Name *

Last Name *

Street Address/Apt./Suite *

1000

City *

State *

Zip *

Phone Number *

Email Address *

Date of Birth *

Job Title *

Department *

Supervisor *

Shift Hired to Work *

Est. Start Date *

Are you being hired as a locum? *

Yes
No

Please answer the following questions related to your ability to complete the job you have applied for. Do You Now or Ever Have:

Any history of allergies? *

Yes
No

If Yes, please explain

1000

Any medical illness, disease or other conditions? *

Yes
No

If Yes, please explain

1000

Currently taking any medications or have been recommended to take any medications you are not taking? *

Yes
No

If Yes, please explain

1000

Currently prescribed or using Medical Marijuana? *

Yes
No

If Yes, please explain

1000

Had any admission to a hospital or surgical procedure completed in the last 5 years? *

Yes
No

If Yes, please explain

1000

Ever been told you have tuberculosis, had a positive test (PPD) for tuberculosis? If yes, did you have an x-ray? Were you treated with and medications? (INH, etc.) *

Yes
No

If Yes, please explain

1000

Had a temporary or permanent residence 1 month or more in any foreign country? *

Yes
No

If Yes, please explain

1000

Traveled outside the US in the past 6 months? *

Yes
No

If Yes, please explain

1000

Ever filed a workers compensation claim or a claim for an injury or accident? *

Yes
No

If Yes, please explain

1000

Suffer from psychiatric/behavioral health disorders (Depression, Bipolar, Anxiety/Panic Attacks, etc.)? *

Yes
No

If Yes, please explain

1000

Have a history of substance abuse, being in a rehab program or under contract with a licensing board? *

Yes
No

If Yes, please explain

1000

Have any concerns with the physical demands of the job you were offered? *

Yes
No

If Yes, please explain

1000

Need a work accommodation for a disability? *

Yes
No

If Yes, please explain

1000

Have any restrictions or limitations? *

Yes
No

If Yes, please explain

1000

Is there anything else about your health you would like us to know? *

Yes
No

If Yes, please explain

1000

Additional Information from Employee

1000

For the employee/volunteer/student:

The above statements are true and complete to the best of my knowledge. I understand that withholding information or misstatements related to my past or present health status may be grounds for termination of employment. I understand that this information will become part of my Employee Health record. I understand that typing my full legal name in the signature box below constitutes my electronic signature

Signature of Employee/Volunteer/Student: *

Date *