EMPLOYEE HEALTH INFORMATION SHEET

1.- Personal Identification

Paternal Surname Mother's Last Name Names

Date of Birth RUT Fono

Address City

2.- State of Health

Weight Height BMI Blood Group

Which operations?

Diseases from which he currently suffers:

Epilepsy Hypertension Diabetes

Enf. Respiratory Heart disease Asthma
Another Which one?

Are you receiving any medical treatment? YES NO

Medication you are taking? How many times a day?

Are you allergic? YES NO

If yes, answer that:

Food Medications Insects Other Which one?

If female, are you pregnant? YES NO

Employee's signature

I certify that the information provided in this Health Record corresponds to reality.