Applicant Medical Information


Posted on May 4, 2012 by admin | in Background Check

MEDICAL INFORMATION


How would you rate your general health?

  • Excellent
  • Fair
  • Good
  • Poor


When was your most recent medical check up?____________________________

Have you ever consulted a physician or been diagnosed for any of the following:

  Yes NO If Yes, Please Explain
1.Prescribed Medicine      
2. Diabetic      
3. Contagious Skin rashes or other skin problems      
4. Frequent illness/viruses      
5. Anemia, mononucleosis or hepatitis      
6. Eating disorders      
7. Severe back or neck pain      
8. Nervous disorders or other mental disorders      
9. Venereal Diseases or A.I.D.S.      
10. Alcoholism or drug dependency      
11. Fainting spells or dizziness      
12. Allergic to certain substances      
13. Smoking      
14.Allegies      
15. Difficulties Seeing/Hearing      
16.Chicken Pox      
17. Health Insurance/company      
18. Eating Disorder      
19. Diagnosed with any illness      
20. Any disabilities which that we should be aware of that would interfere with your capacity to perform certain childcare activities      

My physician is: Name/Address: ____________________________________________________________

Physician Phone: _______________________ we have your permission to contact your physician/hospital, if

Necessary? ___Yes ___No

Signature: ____________________________________________ Date _________________

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