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.

Within the past 12 months have you had: