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Snopac Products Inc.

6118 – 12 Ave So • Seattle, WA 98108 • Tel: (206)764-9230 • Fax: (206)764-5540 • www.snopac.net

HISTORY AND HEALTH ASSESSMENT
Name: ________________________________________________________
Date: _____________________________________________

Soc. Sec. #: ________________________________

Date of Hire: _______________________________________

Home address: _______________________________________________________________________________________________
Phone Number: _________________________________________________

Date of Birth: ________________________________

Family Doctor: __________________________________________________

Dr. Phone # ________________________________

In Case of Emergency Notify: ___________________________________________________________________________________
Relationship to you: __________________________________

Phone No.: ________________________________________

Position Offered: ____________________________________

Department: _______________________________________

1.

Have you ever been employed by Snopac before? No

Yes

Dates:_________________________________________________

2.

Have you ever been injured on or off the job? _____ Dates:____________ If yes, describe the injury/illness:__________________

3.

Have you ever had an illness or injury that required you miss work or school? If yes, describe: _____________________________
________________________________________________________________________________________________________

4.

Have you seen a doctor in the past 5 years? ______ If so, why and when______________________________________________

5.

Are you currently receiving medical treatment? ______If yes, describe: _______________________________________________

6.

Are you currently taking medication of any kind? _____if yes, list:____________________________________________________

7.

Are you allergic to any medications? _____If yes, list:_____________________________________________________________

8.

Do you have any other allergies? _____ If yes, list: _______________________________________________________________

9.

Do you have any hobbies? ___________ What are your hobbies? ___________________________________________________

10. Have you been refused employment or had to leave a job, either temporarily or permanently, because of (circle all applicable
items):
A Sensitivity to chemicals, dust, sunlight, etc.
B Inability to perform certain motions.
C Inability to work in certain positions
D Other medical reasons? If yes, give reasons below:
Reason(s)/Dates: __________________________________________________________________________________
Yes

No

11. Have you had or have you been advised to have any operations? If yes, specify date(s), where and give details:
______________________________________________________________________________________________

Yes

No

12. Have you ever been rendered unconscious? If yes, specify date(s) where and give details:
______________________________________________________________________________________________

Yes

No

13. Have you ever had any sports injuries? If yes, explain type of injury, date(s) thereof and treatment received:
______________________________________________________________________________________________

Yes

No

14. Have you ever made claim(s) for maritime or other employment related benefits? If yes, specify date(s), where
and name(s) of employer(s):

______________________________________________________________________

1

Have you ever been treated at a hospital or hospitalized for any reason whatsoever? If yes. and describe circumstances: ______________________________________________________________________________________________ 27. dusts. explain condition and special arrangement or limitation necessary: ________________________________________________________________ Yes No 23. Have you ever worked at a noisy job? When/where __________________________________________________ Yes No 20. Has your work ever been restricted because of your health and/or any physical problems? If yes. including dates and nature of restrictions: _____________________________________________________________________________ Yes No 18. Do you have any problem which would restrict or make more difficult repetitive lifting or any other heavy physical labor? If yes. please provide details. explain in detail: ______________________________________________________________________ 24. Have you ever been injured in a motor vehicle accident? If yes. GIVE DETAILS IN SPACE PROVIDED): A B C D E F Yes Yes Yes Yes Yes Yes No No No No No No Rejected for employment for medical reasons? Rejected for military service for medical reasons? Discharged from military service for medical reasons? Rejected from an insurance policy for medical reasons? Claimed benefits under workmen’s compensation claim? Exposed to toxic chemicals. specify date(s) location of suit. Date of last dental exam: ___________________ Please explain any recommended treatment that you have not yet had performed: ______________________________________________________________________________ Yes No 26. Do you have any condition requiring a special work assignment or limitation? If yes. radiation or excessive noise? (list specific agents below) G Yes No Treated for emotional breakdown. specify date(s) and for what reason(s)? ______________________________________________________________________ Yes No 16. emotional illness or other mental condition? H Yes No Treated for alcoholism or drug abuse? I Yes No Advised to have a surgical procedure? For MEN Only: Do you have: K Yes No Prostate trouble? L Yes No Burning or discharge from penis? For WOMEN Only: M Yes No Are you pregnant? N Yes No Ever had abnormal Pap Smear? O Yes No Ever been treated for female disorder? P Yes No Breast lumps? Q Date of last menstrual period __________________________________________________________ PROVIDE DETAILS. describe physical discomfort and reason(s): ______________________________________________________________________ Yes No 17. explain circumstances and describe injuries: ________________________________________________________________________________ Yes No 22. fumes. HAVE YOU EVER BEEN (IF ANSWER IS YES. Do you currently have any such work restrictions? Describe: ___________________________________________ Yes No 19. or left handed (check one) 25. Have you ever had a common cold? ______________________________________________________________ Yes No 21. INCLUDED DATE(S) FOR ANY OF ABOVE AFFIRMATIVE RESPONSES: ___________________________________________________________________________________________________________ 2 . mists. specify date(s). Have you ever been a party in a lawsuit? If yes. vapors.Yes No 15. Do you have any physical discomfort when you work in dampness or cold? If yes. Are you right handed .

ankles. hemorrhoid. pain numbness or tingling in hands or wrists Yes No Bursitis – shoulder. colitis. HAVE YOU EVER HAD OR DO YOU HAVE ANY OF THE FOLLOWING: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 Yes No Dizziness Yes No Motion sickness Yes No Fainting spells Yes No Seizures/Epilepsy Yes No Frequent headaches Yes No Migraines Yes No Sinus problems Yes No Thyroid problems Yes No Disorder of eye/ears/nose/throat Yes No Hearing loss Yes No Last hearing test ________________ Yes No Do you wear hearing protection Yes No Full vision in both eyes Yes No Asthma Yes No Hayfever Yes No Emphysema Yes No Tuberculosis Yes No Date of last TB skin test __________ Result_______________________________ Yes No Cough lasting over two weeks Yes No Bloody cough Yes No Night sweats Yes No Unexplained weight loss/gain Yes No Any breathing problems Yes No Have you worked in dust Yes No Cancer or family history Yes No Do you smoke? How many packs per day? ______________ How long? ___________________________ Yes No Other tobacco products? Yes No Any heart problems or family history? Yes No Chest pain Yes No Arthritis/Rheumatism Yes No Any joint discomfort Yes No Any neck problems Yes No Any infections diseases Yes No Any problems in upper or lower extremities Yes No Depression Yes No Any lumps. hands. Surgeries not noted above (please explain) ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ 30. skin rash 76 Yes No Varicose veins. Explanation of positive answers. where _______________________________________________ 29.28. wrist. shoulder 87 Yes No Kidney or bladder problems 88 Yes No Arthritis of any joint 89 Yes No Lameness 90 Yes No Any stitches. or other intestinal problems 55 Yes No Gall bladder problems/surgery 56 Yes No Liver problems 57 Yes No Diabetes or family history 58 Yes No Low blood sugar 59 Yes No Hernia problems/surgery 60 Yes No Venereal disease 61 Yes No Hemorrhoids 62 Yes No Blindness in one or both eyes 63 Yes No Hernia problems/surgery 64 Yes No Urinary difficulty 65 Yes No Kidney stones 66 Yes No Shooting pains 67 Yes No Tingling/numbness in any part of body 68 Yes No wrist discomfort 69 Yes No Wear a brace/support 70 Yes No Head injury 71 Yes No Foot problems 72 Yes No Bleeding disorders 73 Yes No Tested for hepatitis 74 Yes No Hepatitis 75 Yes No Skin disease. such as stomach ulcers. specify dates where applicable: ___________________________________________________________________________________________________________ 3 . Medical problems not noted above (please explain) ___________________________________________________________________________________________________________ 31. or wrists 84 Yes No Wear a back brace or support 85 Yes No Locking fingers 86 Yes No Tendinitis –hand. or leg pains 77 Yes No Back problems/complaints or 78 Yes No Mental problems 79 Yes No Pain or numbness in legs 80 Yes No Herniated or ruptured disc 81 Yes No Back surgery 82 Yes No Any knee problems 83 Yes No Swelling of legs. elbow. elbow Yes No Chronic sore throat Yes No Sprains of joints Yes No Any broken bones where _____________________________ Yes No Pain/pressure in chest Yes No Mental problems Yes No Nervous trouble of any sort 44 45 46 47 48 49 50 51 52 53 54 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Cramps No Date of last tetanus ____________ No Shortness of breath No Irregular heartbeat No Heart murmur No Rheumatic fever No Heart problems No High blood pressure No Family history of high blood pressure No Any disease or disorder of the blood No Any disease or disorder of stomach.

brothers. poses a direct threat to the health or safety of the employee or others and no reasonable accommodation was available that would enable you to perform the essential functions without a significant risk to health or safety. since this indicates a failure to appropriately consider the company’s requests for information. It is company policy that inadequately completing company documents may be grounds for denial of employment. or any other applicable benefits. Check any illnesses below which have occurred in parents. _________________________________________________________ SIGNATURE 4 __________________________________ Date . MISREPRESENTATION OR OMISSION. explain fully and indicate the date(s) when you had such illness(es) orinjuries:_______________________________________________________________________________________ ___________________________________________________________________________________________________________ Conditional offer of hire may be withdrawn if the job-related disability. I UNDERSTAND THAT ANY FALSIFICATION. I CERTIFY THAT THE FACTS AND INFORMATION IN THIS HEALTH QUESTIONNAIRE AND IN ANY ATTACHMENTS OR SUPPORTING DOCUMENTS ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.32. or immediate termination. Additionally. Have you had any illness(es) or injuries other than those already listed? If yes. WILL BE CAUSE OF DENIAL FOR EMPLOYMENT OR IMMEDIATE TERMINATION. Inadequate completion includes drawing a line through the “no” responses. If you use tobacco. AS WELL AS ANY MISLEADING STATEMENTS OR OMISSIONS. sisters. REGARDLESS OF WHEN OR HOW DISCOVERED. The terms “misrepresentation” or “omission” include failure to seriously consider and complete this assessment form and other similar forms. denial of maintenance and/or cure. Family History. false or misleading answers may be a basis for denial of benefits under federal maritime law or State worker’s compensation schemes. withdrawal of conditional job offer. consistent with business necessity. indicate which relative: Diabetes Heart Disease Tuberculosis High blood pressure Epilepsy Stroke Asthma Cancer Kidney disease Blood disease Low back pain 36. Do you use alcohol? ____________ How often? _________________________________________________________________ 33. when did you begin using tobacco? ____________________________________________________________ 34 Do you wear glasses or contact lenses? _________________________________________________________________________ 35. or the accommodation would cause undue hardship.

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