REON ENERGY SOLUTION

HEALTH STATUS QUESTIONNARE (HSQ)

Candidate Name: Date of Birth:
Please tick mark
Sr. CNIC No: Job Type : Office o Field:Sales o Field:Work at Height
(ü) on No/Yes as
No. Mobile #: o Field:Work in confined spaces appropriate

Instructions: Please answer the questions by ticking the correct box. If you are not sure, leave the question blank and our Health
Advisor will contact you. Our Health Advisor may ask you additional questions during the examination.
No Yes
Are you currently being treated by a doctor for any illness or injury?
If yes please briefly describe
1

No Yes
Are you receiving any medical treatment or taking any medication (either prescribed or otherwise)?
If yes please list
2

No Yes
3 Have you ever had, or been told by a doctor that you had any of the following?
3.1 High blood pressure
3.2 Any allergy (from any drug, or other substance?)
3.3 Heart disease
3.4 Chest pain, angina
3.5 Any condition requiring heart surgery
3.6 Palpitations/irregular heartbeat
3.7 Abnormal shortness of breath
3.8 Head injury, spinal injury
3.9 Seizures, fits, convulsions, epilepsy
3.1 Blackouts, fainting
3.11 Stroke
3.12 Dizziness, vertigo, problems with balance
3.13 Double vision, difficulty seeing
3.14 Color blindness
3.15 Kidney disease
3.16 Diabetes
3.17 Neck, back or limb disorders
3.18 Hearing loss or deafness or had an ear operation or use a hearing aid
3.19 Do you have difficulty hearing people on the telephone (including use of hearing aid if worn)?
3.20 Have you ever had, or been told by a doctor that you had a psychiatric illness, or nervous disorder?
3.21 Have you ever had any other serious injury, illness, operation, or been in hospital for any reason?
3.22 Have you ever had, or been told by a doctor that you had a sleep disorder, sleep apnoea, or narcolepsy?
3.23 Has anyone noticed that your breathing stops or is disrupted by episodes of choking during your sleep?
3.24 Do you have a history of Alcoholism (excessive drinking)
4 Please share genetic health risks if any. State any strong family history of any illness:

No Yes
5 Do you use drugs or have any sort of addiction?
5.10 Have you
Do you useever
anybeen
drugstreated for alcohol
or medications notorprescribed
drug/substance
for youabuse
by a doctor?
6 If yes list here.
Have you ever been declined a job offer on account of not meeting fitness to work medical evaluation criteria
7 If Yes, please give details:
8 Have you been vaccinated against Hepatitis B (If yes, provide a copy of vaccination card)
9 Have you been vaccinated against any other illness? (Please state which one and provide a copy of vaccination card)

DECLARATION:
I hereby, state that all of the information provided above is correct and complete to the best of my knowledge. I understand that withholding or
misrepresenting information may lead to the offer of employment being withdrawn or employment terminated.
Signature: Date:
For Office use only
Company Health Advisor’s comments:
Date: Health Adviser Name: Signature