Employee Medical Questionnaire
Employee medical questionnaires are questionnaires given to employees for the purpose of finding out their medical conditions. Employee medical questionnaires are normally completed by prospective employees before being employed or at any other time that the employer might require that information. The employee medical questionnaire asks personal questions about the individual’s condition. The main purpose of designing a medical questionnaire is to find out whether the employee is medically fit to carry out the responsibilities and duties that the job entails. Below is an example of a medical questionnaire.
First name Middle name Last name
___________________ ____________________ _________________
Marital status (please tick one)
Single __________ Married _________ Other ________
Do you have any children?
Yes _______ No ________
If answer is ‘yes’ in above state the number of children you have.
Position in the organization ________________
Kindly, answer the following questions with ‘yes or no’
Are you physically disabled?
Do you use hearing aids or contact lenses/glasses?
Do you have health insurance?
Have you fallen sick in the past six months?
Do you have any illness that requires you to be constantly on medication?
Have you ever been addicted to drugs or alcohol?
Have you had a major surgery in the last one year?
Does your family have a history of any of the following diseases?
Heart disease _______
Would you be willing to undergo an independent medical examination by the company’s doctor?
Category: Medical Questionnaire