Health/Medical Questionnaire for Health Force of Georgia

If there is any question or statement on this form that you do not understand, ask for assistance by calling Cindy Smith, Vice President, Operations at Health Force of Georgia: 770-458-8500 ext. 704.

Thank you for completing the caregiver career application at Health Force of Georgia. There are three sections to the Health/Medical Questionnaire form. Be sure to complete ALL sections before clicking submit. The form will prompt you if there is required information missing in any section. Fields marked with a red * are required.

"*" indicates required fields

Employee Name*

First Middle Last

The Georgia Subsequent Injury Trust Fund protects employers from excess liability for worker’s compensation when an injury to a worker merges with a preexisting impairment to cause a greater liability than would have resulted from the subsequent injury alone. In order to qualify for this protection, we must have prior knowledge of any preexisting illness or other ailment/injury you may have sustained in the past that may contribute to a percentage of permanent impairment. The presence of one or more impairments does not automatically render you unfit as an employee. All decisions will be made on job-related criteria. Reasonable accommodation will be made if appropriate, provided it does not pose an undue hardship.

1. Health Questions: Have You Ever Had...

Asthma?*

Yes

Migraine Headaches?*

Yes

Head Injury?*

Yes

Heart Trouble?*

Yes

Fainting Spells or Dizziness?*

Yes

Swelling in Ankles or Legs?*

Yes

Skin Rash or Eczema?*

Yes

Joint Pain or Arthritis?*

Yes

Epilepsy, Convulsions or Seizures?*

Yes

Cancer?*

Yes

Stomach Problems or Ulcers?*

Yes

Hepatitis?*

Yes

Thyroid Problems?*

Yes

Bladder Problems?*

Yes

Any serious wrist problem or Carpal Tunnel Syndrome?*

Yes

Surgery For Carpal Tunnel Syndrome?*

Yes

Surgery When?*

Which Hand?*

Left

Right

Work related illness or injury?*

Yes

When?*

What type?*

Varicose veins?*

Yes

Anemia or Sickle Cell Anemia?*

Yes

Tendonitis?*

Yes

Repetitive Motion Disorder?*

Yes

Stiffness of major weight bearing joints?*

Yes

Do you need glasses/contacts to read or for distance?*

Yes

Hay Fever?*

Yes

Diabetes?*

Yes

Color Blindness?*

Yes

Cerebral Palsy?*

Yes

Multiple Sclerosis*

Yes

Gallbladder Problems?*

Yes

Rheumatic Fever?*

Yes

Any Broken Bones?*

Yes

Which bone?*

Date Broken?

Had any type of surgery?*

Yes

Surgery When?*

What type of surgery?*

Reaction to any drugs?*

Yes

Which drugs?*

Cardiovascular Disorder?*

Yes

Tuberculosis?*

Yes

Hemophilia or bleeding disorder?*

Yes

Chronic infection of bone?*

Yes

Muscular Dystrophy?*

Yes

Ruptured disc?*

Yes

Wear a neck brace?*

Yes

Back injury?*

Yes

Back injury when?*

Had back surgery?*

Yes

Back surgery when?*

Difficulty or loss of hearing?*

Yes

Back trouble or pain?*

Yes

Hernia?*

Yes

High blood pressure?*

Yes

Take medication to control high blood pressure?*

Yes

Low blood pressure?*

Yes

Mental illness?*

Yes

Reaction to chemicals?*

Yes

Breathing problems or emphysema?*

Yes

Venereal Disease?*

Yes

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END SECTION: Health Questions

2. Have You Ever Had....

Partial loss of uncorrected vision of more than 75 percent bilaterally?*

Yes

Psychoneurotic disability following confinement for treatment in a recognized medical or mental institution for a period greater than 6 months?*

Yes

Any permanent condition that constitutes 20 percent impairment of a foot, leg, hand or of the body as a whole?*

Yes

Do you or have you within the past year participated in recreational drug use?*

Yes

Have you ever participated in a drug abuse treatment program?*

Yes

Where?*

Do you currently take any prescription medication?*

Yes

If so, what?*

Do you have any condition or have you sustained any injury that would have an effect on your capacity to perform your job duties?*

Yes

Please explain*

Have you ever been hurt on the job or filed a worker’s compensation claim in the past?*

Yes

How many times?*

What years?*

Estimate the number of workdays you have lost in each of the past two years.*

Of these workdays lost, how many were due to illness or injuries?*

Please list the name of any doctors you have seen in the past two years. List your family doctor first.*

Type none if you have not seen or have a doctor.

Please provide any pertinent facts to every previous ailment or injury contributing to impairments, as well as all previous worker’s compensation claims.*

Type none if this does not apply to you.

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End of Have You Ever Had....

3. For the job title of Healthcare Provider, you must be able to perform these functions or tasks:

1. Stand for long periods of time during your shift.*

Yes

2. Grip, grasp and twist using your hands and wrists.*

Yes

3. Lift, turn and/or carry up to 100 lbs. regularly during your shift.*

Yes

4. Climb stairs (with loads up to 25 lbs.)*

Yes

5. Wear proper safety equipment (goggles, gloves & mask.)*

Yes

6. Understand hazard communication and safety information.*

Yes

7. Able to safely drive a car.*

Yes

8. Demands of the client.*

Yes

9. Able to move intermittently throughout the workday, inclusive of sitting, standing, bending, pulling or moving objects and patients.*

Yes

Based on the information discussed and/or received, I feel that I*

Can perform the essential function of the job we’ve discussed.

Cannot perform the essential function of the job we’ve discussed.

If you cannot perform one or more of the job requirements noted above, and you feel we can modify any part of the job and/or schedule to enable you to do the work, please explain in the space provided. * Job modifications will be addressed on a case-by-case basis.

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END SECTION For the job title of Healthcare Provider, you must be able to perform these functions or tasks:

If there is any question or statement on this form that you do not understand, ask for assistance by calling Cindy Smith, Director of Operations: 770-458-8500 ext. 704.

Our Worker’s Compensation Insurance Carrier checks for previous claims by name and social security number. If you have had a precious claim or injury, and fail to make us aware of it, you may legally be denied future benefits in the event of a new injury by operation of the landmark Rycroft ruling. For you own protection, please make us aware of any previous injuries.

I certify that the above answers are true to the best of my knowledge and understand that any false statements or omissions will make my subject to discharge.*

First Last

I consent to my submitted data being collected and stored*

Yes

Name

This field is for validation purposes and should be left unchanged.