ࡱ> #%" bjbj 42hh@ 338$C,!'4o(& &&&&&&&$U(*v&]a"&33&[[[p388&[&[[r$Tk%e-pL%&&0!'Z%Vm+0m+%%8m+%[&&!'m+ :  For applicants who have received a conditional job offer. The statement as found on this page must be signed by the applicant before completing the following questionnaire. I herewith affirm that the employer has made me an offer of employment, conditioned on the satisfactory completion of this questionnaire and, if necessary, within the sole discretion of the employer, a medical examination. The purpose of this inquiry is to determine whether I currently have the physical or mental qualifications necessary to perform the job that has been offered, and what accommodations, if any, may be necessary, so that I can perform the job without posing a direct threat to the health or safety of myself or others and for the purposes and reason as stated on the attached questionnaire. I herewith affirm that the questions as found in the attached medical questionnaire have not been asked of me by anyone with the employer until after I have signed this statement and been offered a job. Name (please print): ____________________________________________________________________ Social Security number: _________________________________________________________________ *If I do not give accurate and truthful information on this Medical History Questionnaire, which forms the second and final part of my employment agreement, the entire employment agreement shall be considered null and void. CONDITIONAL EMPLOYMENT ENTRANCE MEDICAL QUESTIONNAIRE Have you ever had or been treated for any of the following conditions or diseases?  EMBED Excel.Sheet.8   EMBED Excel.Sheet.8  IF YOU ANSWERED YES TO ANY OF THE ABOVE QUESTIONS, PLEASE EXPLAIN ON THE BACK PAGE Please list any condition or disease for which you have been treated in the past three (3) years. If none, state none. _______________________________________________________________________________________________________________ Have you ever been hospitalized? If so, for what conditions? If none, state none. _______________________________________________________________________________________________________________ Have you ever been treated by a psychiatrist or psychologist? If so, for what condition? If none, state none. _______________________________________________________________________________________________________________ Have you ever been treated for any mental condition? If so, for what condition? If none, state none. _______________________________________________________________________________________________________________ Is there any health related reason you may not be able to perform the job for which you are applying? If yes, explain. _______________________________________________________________________________________________________________ Have you had a major illness in the past five (5) years? If none, state none. _______________________________________________________________________________________________________________ In the last year, did you exceed your allotted authorized time off? If none, explain. _______________________________________________________________________________________________________________ Do you have any physical defects which preclude you from performing certain kinds of work? If yes, explain. If none, state none. _______________________________________________________________________________________________________________ Do you have any disabilities or impairments which may affect your performance in the position for which you are applying? If none, state none. _______________________________________________________________________________________________________________ Are you taking any prescription drugs? If so, list the medications. If none, state none. _______________________________________________________________________________________________________________ Have you ever been treated for drug addiction or alcoholism? If yes, explain in detail. If none, state none. _______________________________________________________________________________________________________________ PLEASE EXPLAIN ANY YES ANSWER BELOW _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ MISREPRESENTATIONS AS TO PRE-EXISTING PHYSICAL OR MENTAL CONDITIONS MAY CAUSE FORFEITURE OF YOUR WORKERS COMPENSATION BENEFITS. Signature: ____________________________________________________________ Date: ________________________________________________________________      PROPRIETARY and CONFIDENTIAL PersoNet 2008 Medical History Questionnaire  x 56789ﭛ~iZE7hq\CJOJQJ^JaJ)jWh?h?CJOJQJU^JaJj^K h?CJUVaJ)jh?h?CJOJQJU^JaJjc^K h?CJUVaJh?CJOJQJ^JaJ#jh?CJOJQJU^JaJh7CJOJQJ^JaJ#hq\h76CJOJQJ^JaJ hq\hVeCJOJQJ^JaJ hq\hN]CJOJQJ^JaJ hq\h7CJOJQJ^JaJ  ; < w x 9: L]L^gdq\ L]L^gd p$L]L^a$gd$L]L^a$gd7xy@A#$w9:rL]Lgd? L8]L^8gd? & FL]Lgd.qq L]L^gd?_ewy'-?A "$vwY_qPVhSYk"(:  #{[as±±±±±±УУ±±±±±±±±±hCJOJQJ^JaJ h?hCJOJQJ^JaJhCJOJQJ^JaJ h?h?CJOJQJ^JaJ h?h.qqCJOJQJ^JaJh?CJOJQJ^JaJ@rsijlm;< D$ $L]La$gd? & FL]Lgd?L]Lgd? & FL]Lgd.qq L8]L^8gd?tT4'()qrsL]Lgd? $L]La$gd $L]La$gd? 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