POST JOB OFFER MEDICAL QUESTIONNAIRE

x
Complete name: _________________________________________
Jorge Rosales Cuaxiloa Sex: ____M____F
22 Poniente 121 neighborhood of Santiago Mixquitla, San Pedro Cholula, Puebla.
Address: ________________________________________________________________________________
Puebla.
City State Zip Code72769Telephone # 2225297821

production technician
Job Position offered: ___________________________Date November 03, 1990
of Birth:__________________________________
Deyra Perez 2224615644
Emergency contact:_______________________________________Telephone #:_______________________
February 17, 2022 71
Hire date:_______________ Height:________________
1.70 Weight:___________________

*Falsification of information by applicant can result termination from eomployment or

conditional job offer being revoked.

Please indicate whether you have EVER IN YOUR LIFETIME had any of the following conditions: if YES,
indicate the dates the condition occurred and give detailed explanation on back of page:

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 POST JOB OFFER MEDICAL QUESTIONNAIRE

x x
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Have you ever had ANY injuries on the job? YES___ NO___
x

If “YES”, how many?_____ For each; list the date of injury, employer, part of body affected, cause, amount of
lost time, percentage of disability and whether workers comp claim was filed:
_________________________________________________________________________________________
_________________________________________________________________________________________
_____________________________________________________________________________________

Do you or have you had other injuries or illnesses not on the job (such as home, auto, sports, hunting, etc.)
that have result in hospitalization, surgery or lost time from work? YES_____ NO____
x

If “YES”, how many?_____For each; list the date of injury/illness, body part affected, cause, days in hospital,
days of lost time from work and if there is any disability:
_________________________________________________________________________________________
_________________________________________________________________________________________
__________________________________________________________________________________

Please list any and all medications prescribed to you in the past 12 months:
paracetamol, aspirin
_________________________________________________________________________________________
___________________________________________________________________________________

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 POST JOB OFFER MEDICAL QUESTIONNAIRE

OCCUPATIONAL HISTORY

Check YES or NO column for the following. If YES, please provide additional information, including dates,
description of injury or accident and name of employer.

YES NO Have you ever been rejected or rated up for insurance, rejected for employment or
x
___ ___ rejected by the Armed Forces because of your physical contidion?

Explain:

x
___ ___ Have you worked in an area you were exposed to increased amounts of dust? If yes,
where and when?

Explain:

x
___ ___ Have you worked in a noisy environment? If so, what were the noise levels? If unknown
describe how noisy was. (For example: I had to shout to talk to the person standing
within 1 foot of me.) List employer names and dates of employment:

Explain:

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 POST JOB OFFER MEDICAL QUESTIONNAIRE

YES NO

___ ___
x Do you have allergies or a reaction to ANY specific drugs, substances or chemicals?
If YES, please list:

Explain:

x
___ ___ Have you EVER been exposed to any potentially harmful substance? (For example:
asbestosis, silica, benzene, lead cadium, or other subtance.)

Explain:

___ ___
x Have you EVER had ANY injury to your neck or ANY part of your back, or had ANY kind
of neck, mid back or low bac ailment, problems or complaints? If YES, describe in detail:

Explain:

x
___ ___ Has YOUR work EVER been limited or restricted because of your heatlh? If YES, explain:

Explain:

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 POST JOB OFFER MEDICAL QUESTIONNAIRE

YES NO
x
___ ___ Have you been hospitalized? If YES, explain:

Explain:

x
___ ___ Have you ever filed a worker’s compensation claim or received benefits of ANY kind for a
work injury or disease? If YES, describe and give the dates and indicate whether such a
claim is still open, and what is the nature of the injury or injuries:

Explain:

x
___ ___ Have you received payments as a result of a physical or mental disability? If YES,
explain:

Explain:

x
___ ___ Have you lost time from work due to injury or illness during the last 10 years? If YES,
give approximate of days:

Explain:

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 POST JOB OFFER MEDICAL QUESTIONNAIRE

YES NO

___ x
___ Do you have any condition which may require special work assignment? If YES, explain:

Explain:

x
___ ___ Have you been treated, lost time from work, or required modified work activity as a
result of a diagnosis for CTS (Carpal Tunnel Syndrome), De Quervain’s, Cubital Tunnel
Syndrome, Baker’s Cyst, Ganglion Cyst, Tendinitis, Tenosynovitis, or Raynaud’s
Phenomenon? If YES, explain:

Explain:

___ x
___ Have you ever had knee or shoulder surgery? If YES describe the cause for the need of
surgery:

Explain:

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 POST JOB OFFER MEDICAL QUESTIONNAIRE

YES NO

___ ___
x Do you have ANY disability requiring ANY accommodation? If YES, identify the disability
and request accommodation:

Explain:

x
___ ___ Are you pregnant? If YES, state your expected date of delivery and any medical
restrictions which you have:

Explain:

___ ___
x Have you had ANY surgery in the past 10 years? If YES, please explain what type of
surgery and state if any disability arose from this procedure(s):

Explain:

x
___ ___ Have you EVER had ANY symptoms, problems, complaints, or treatment to/of an internal
organ? If YES, please explain:

Explain:

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 POST JOB OFFER MEDICAL QUESTIONNAIRE

___ ___
x Have you EVER had COVID-19? If YES, please explain when and the treatment you had:

Explain:

x
___ ___ If your last answer was YES, have you had another COVID-19 test? If YES, please
explain where and result:

Explain:

x
___ ___ Have you been in contact with a person with COVID-19 in the past 15 days? If YES,
explain who, where, when, and if you took a test:

Explain:

I certify that the above answers are true and complete. I am aware that any falsification of the
facts on the above . may be grounds for revocation of employment or discharge. I authorized the
release of any physical examination required by the employer to a representative of my
employer.
February 17, 2022
Date:__________________________________ Signed:_________________________________________

Printed name:____________________________________

Employer witness to signature:________________________________________________________________

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