B-JOURNALIER LIFT – ANG Étape 1 sur 26 3% INSTRUCTION .The form is forwarded under confidential cover to the medical clinic. A review of the questionnaire will be conducted by the clinic staff with you by phone f you are having difficulty or think you need a reader, you can call us at any time at 1 (877) 606-8111 (toll-free number). Enter the identification number you received* Password* What's the company name that you apply for ? Confirmation of your identificationLast name* First name* Date of birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Format of the date field : dd/mm/yyyyProvince*AlbertaColombie-BritanniqueManitobaNouveau-BrunswickTerre-Neuve et LabradorTerritoires du Nord-OuestNouvelle-ÉcosseNunavutOntarioÎle du Prince-ÉdouardQuébecSaskatchewanYukonE-mail Phone number (1)*Phone number (2)Job title Best time to contact you* AM PM SOIR - Evening OCCUPATIONAL HISTORY094 - What is your height? (indicate: meter or feet)* 093 - What is your weight? (Indicate: pounds or kilogram)* 091 - Following an operation, did you have a decrease in your physical capacity?* Yes No Specify070 - Are you waiting for an operation requiring hospitalization?* Yes No Specify OCCUPATIONAL HISTORYDo you have health problems from exposure : :076 - Activities involving repetitive movements ?* Yes No Specify075 - Significant efforts* Yes No Specify ENT001 - Do you suffer from deafness (hearing loss) ?* Yes No Since what year ?* Specify*039 - Do you suffer from discharge, buzzing noises (tinnitus)?* Yes No Since what year ?* Specify*004 - Within the last year, did you suffer from vertigo ? If so, specify the frequency ?* Yes No How often ?* Specify*002 - Do you suffer from Meuniere disease (ear infection)?* Yes No Since what year ?* Specify* VISION003 - Do you suffer from double vision?* Yes No Since what year ?* Specify*005 - Do you have cataracts?* Yes No Since what year ?* Specify*006 - Do you suffer from a decrease in your visual ability that is not corrected?* Yes No Since what year ?* Specify*090 - Do you have a decrease in your perimeter field of vision?* Yes No Since what year ?* Specify*063 - Do you have trouble distinguishing colors?* Yes No PULMONARYDO YOU SUFFER OR HAVE YOU SUFFERED :038 - Chronic bronchitis?* Yes No Specify*037 - Emphysema ?* Yes No Specify*036 - Asthma* Yes No Specify*007 - Do you suffer from a lung disease?* Yes No Specify* PULMONARYDURING THE LAST YEAR, HAVE YOU SUFFERED :079 - Shortness of breath on mild exertion ?* Yes No Specify* NERVOUS SYSTEM040 - Do you suffer from paralysis of the upper or lower limbs?* Yes No Since what year ?* Specify*009 - Have you been diagnosed with the Parkinson disease?* Yes No Since what year ?* Specify*008 - Do you suffer of epilepsy ?* Yes No Since what year ?* Specify* NERVOUS SYSTEMDO YOU SUFFER OR HAVE SUFFERED DURING THE LAST YEAR :010 - Of convulsions ?* Yes No Frequency* Specify*012 - Diziness ?* Yes No Frequency* Specify*011 - Lost of consciousness ?* Yes No Frequency* Specify*112 - Of a disease affecting mobility/locomotor system ?* Yes No Specify* ILLNESSES026 - In the past 5 years, have you had a heart problem? If YES (specify)* Yes No Specify*027 - Do you have acute episodes of venous thrombosis?* Yes No Specify* ILNESSESDO YOU SUFFER OF HAVE YOU SUFFERED :025 - Do you suffer from diabetes?* Yes No Since what year ?* Specify*017 - Arthritis or arthrosis?* Yes No Specify* ILLNESSESDURING THE LAST YEAR, HAVE YOU SUFFERED FROM :083 - Severe headaches ?* Yes No How often ?* SLEEP DISORDER028 - Do you suffer of narcolepsy ?* Yes No Since what year ?* Specify*029 - Do you sleep apnea? If YES, do you have a device to correct this sleep disorder?* Yes No Since what year ?* Specify*084 - During the last year, did you suffer from insomnia ?* Yes No At what frequency ?* Specify* DRUGS AND ALCOHOL030 - Has a doctor diagnosed you with a substance use disorder (alcohol or drugs)?* Yes No Since what year ?* Specify*068 - Do you have or have you ever used drugs?* Yes No Frequency* Specify* MUSCULO-SKELETALAre you :* Right-handed Left-handed MUSCULO-SKELETALDO YOU SUFFER OR HAVE YOU SUFFERED :020 - Herniated disc ?* Yes No Specify*021 - Cervical disc ?* Yes No Specify*022 - Lombar disc ?* Yes No Specify*018 - A sprain ?* Yes No Specify*088 - Back pain or difficulty transporting objects?* Yes No Specify* MUSCULO-SKELETALDO YOU SUFFER OR HAVE YOU SUFFERED :015 - Carpal tunnel syndrome ?* Yes No Identify the wrist(s)* Right Left Specify*016 - Tendinitis, bursitis, epicondylitis (tennis elbow), epitrochleitis?* Yes No Specify* MUSCULO-SKELETALDO YOU HAVE DIFFICULTY TO :087 - Keep your head fixed for a long period of time?* Yes No Specify*046 - Going up and down stairs ?* Yes No Specify*048 - Kneeling or crouch ?* Yes No Specify*049 - Keep your balance ?* Yes No Specify* MUSCULO-SKELETALARE YOU LIMITED :089 - On the weight you can lift or carry because of a medical condition ?* Yes No Specify*019 - In your movements or do you have any other condition ?* Yes No Specify MUSCULO-SKELETALDO YOU FEEL PAIN WHEN YOU SOLICIT :052 - Your wrists, your elbows, your arms or your shoulders ?* Yes No Specify*124 - Your hands, hips, knees, ankles, feet?* Yes No Specify* MUSCULO-SKELETALDO YOU SUFFER OR HAVE YOU SUFFERED :112 - Of a disease affecting the mobility/locomotor system?* Yes No Specify*044 - Any other condition and in this case which condition ?* Yes No Specify* PREVIOUS DISEASES AND ACCIDENTSHAVE YOU BEEN DIAGNOSED WITH PERMANENT FUNCTIONAL LIMITATIONS :031 - After an occupational disease, work accident, car accident, or other acident or illnesses?* Yes No In what year ?* Nature of the lesion* Work stopping* Yes No How much time* Have you been on temporary assignment?* Yes No Do you have limitations ?* Yes No Specify the nature of the limitationsDo you want to report another accident? (2)* Yes No Since what year ?* Nature of the lesion* Work stopping ?* Yes No How much time ?* Have you been on temporary assignment?* Yes No Do you have limitations ?* Yes No Specify the nature of the limitationsDo you want to report another accident? (3)* Yes No Since what year ?* Nature of the lesion* Work stopping* Yes No How much time ?* Have you been on temporary assignment?* Yes No Do you have limitations ?* Yes No Specify the nature of the limitations GENERAL100 - Have you used, in the last 3 years, medication for psychological condition ?* Yes No Specify032 - Are you suffering from any illness, injury or pain not mentioned in this questionnaire that would prevent you from occupying the position you are applying for?* Yes No Specify*033 - Actually, are you undergoing any medical treatments that would prevent you from occupying the position you are applying for? * Yes No Specify*034 - Are you currently taking any medications that may decrease your alertness? If YES (Specify)* Yes No Specify035 - Are you currently taking any prescribed medication related to the previous questions of this questionnaire?* Yes No Specify* I, the undersigned :* Add your first and last name Confirmations* I declare that the answers I have given to the questions contained in this medical questionnaire are accurate and complete I acknowledge that Lizotte Médico-Experts may ask me for clarification regarding my answers to the questions contained in this pre-employment medical questionnaire and, if applicable, I agree to provide accurate and complete details. In addition, I understand that Lizotte Médico-Experts will prepare a report containing its conclusions from my answers to this questionnaire. I authorize Lizotte Médico-Experts to forward its report and all information on my health to the applicant and I understand that this report will belong to the latter and that a request for a copy should be sent to him. Finally, I acknowledge that my answers will be used to determine whether my state of health is compatible with the job I have applied to and, therefore, I acknowledge that giving false or misleading information could justify the applicant's not hire me or break my employment relationship. Signature* Δ
