Medical History Form – Uplifted Care Services

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Home
About
- Who We Are
- Employment Application Form
Services
Resources
- COVID-19
Contact
My Account
- Login / Register

Employee Medical History Form

Name *

First

Last

Are you presently under the care of a Physician for a medical condition? *

Yes
No

If Yes, what kind of conditions?

List any Allergies or reactions:

List previous surgeries and year of procedure:

List illnesses and year treated:

High Blood Pressure:

Yes
No

If YES, explain in the text box provided far below

Hernia:

Yes
No

If YES, explain in the text box provided far below

Diabetes:

Yes
No

If YES, explain in the text box provided far below

Seizures:

Yes
No

If YES, explain in the text box provided far below

Arthritis:

Yes
No

If YES, explain in the text box provided far below

Broken Bones:

Yes
No

If YES, explain in the text box provided far below

Respiratory Problems:

Yes
No

If YES, explain in the text box provided far below

Mental Problems:

Yes
No

If YES, explain in the text box provided far below

Smoke:

Yes
No

If YES, explain in the text box provided far below

Alcohol Abuse:

Yes
No

If YES, explain in the text box provided far below

Stomach:

Yes
No

If YES, explain in the text box provided far below

Drug Use/Abuse:

Yes
No

If YES, explain in the text box provided below

Explanation if a YES on any of the above:

Is there any health-related reason you may not be able to perform the job for which you are applying?

Yes
No

If YES, please explain

Are there any reasonable accommodations which the Agency would have to provide in order for you to meet the daily requirements of the job?

Yes
No

If Yes, please specify:

I attest that the information provided above is accurate to the best of my knowledge.

Yes, I Agree
No, i Disagree

Email

1-888-588-3166

Uplifted Care Services
3340 Brookdale Dr. N
Brooklyn Park, MN 55443

upliftedcareservices@gmail.com

Mon - Fri : 9:00 AM - 5:00 PM
Sat - Sun : Closed

Home
About
- Who We Are
- Employment Application Form
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