Risk Asssessment Form

* = Required Information

Employee Health Risk Assessment Questionnaire

Employee Name*

Position Applied for*

Please Answer the Questions below and return this Questionnaire to Elohim Medical Staffing Agency, Inc.( If “Yes” please giveexplanation on comment line below)

Have you ever had any illness that may have been caused by or made worse by your work?

Yes

Unknown

Do you consider yourself as having disability? If yes, do you need any adjustments or modifications todo the job you have applied for?

Yes

Unknown

Have you ever had Active, Untreated Tuberculosis?

Yes

Unknown

Any disease associated with severe immunologic deficiency?

Yes

Unknown

Have you ever had HIV or any other STD?

Yes

Unknown

Have you ever had Epilepsy, seizures, sudden unexplained dizziness or loss of consciousness

Yes

Unknown

Do you have difficulty bending, standing, lifting or any other movements?

Yes

Unknown

Have you ever had any mental illness or psychological problems including depression, anxiety,schizophrenia etc.

Yes

Unknown

Have you ever had any drug or alcohol related problems?

Yes

Unknown

Comments

Do you currently have:

1) Unexplained fever

Yes

2) Unexplained weight gain or weight loss?

Yes

3) Unexplained fatigue of malaise(More than 3 weeks)

Yes

4) Night Sweats

Yes

5) Unexplained loss of appetite

Yes

6) Cough lasting more than 3 weeks (Non related to Viral upper infection or chronic lung disease)

Yes

7) Coughing up blood

Yes

8) Any exposure to tuberculosis or any othercommunicable diseases in the past

Yes

Comments

I certify that I have read this document answered all the questions to the best of my Knowledge and Ability

Employee Name

Date