Employee Name: ID #: Date: MM slash DD slash YYYY This annual physical assessment is not intended to be a complete physical examination, nor to replace medical care by your own physician. This is to certify, that o the best of my knowledge, there is no health impairment present that is of potential risk to me, patient, family, or other employees, or that may interfere with the performance of my duties. I certify that I am free from habitation or addiction to depressants, stimulants, narcotics, alcohol, or other drugs or substances which may alter my behavior. I understand that any falsification or misrepresentation of medical facts will be sufficient grounds for my release from employment.Employee Signature: (Подпись):Within the past 12 months have you had:CONDITIONCONDITIONSurgerySurgery Yes No Digestive ProblemsDigestive Problems Yes No FracturesFractures Yes No DiabetesDigestive Problems Yes No Disabling InjuryDisabling Injury Yes No Loss of WeightLoss of Weight Yes No HerniaHernia Yes No ArthritisArthritis Yes No Chronic back pain/injuryChronic back pain/injury Yes No Have you noticed lumps or nodules in your breast?Have you noticed lumps or nodules in your breast? Yes No Fainting SpellsFainting Spells Yes No Problem with habituation or addiction to alcohol, depressants, stimulants, narcotics or other substances that may alter behaviorProblem with habituation or addiction to alcohol, depressants, stimulants, narcotics or other substances that may alter behavior Yes No SeizuresSeizures Yes No Have you been treated for an infectious condition?Are you or have you been restricted in the kind or amount of work you do? Yes No Mental IllnessMental Illness Yes No Are you or have you been restricted in the kind or amount of work you do?Are you being treated for a medical condition? Yes No Chronic CoughingChronic Coughing Yes No Are you being treated for a medical condition?Have you been treated for an infectious condition? Yes No Asthma-AllergiesAsthma-Allergies Yes No Explanation of “YES” answers:PhoneThis field is for validation purposes and should be left unchanged.