B-ELECTROMECHANIC MECHANIC – ANG Étape 1 sur 29 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 If 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* Birth date*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Format : 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 TO :075 - Significant physical 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* OPHTALMOLOGIC003 - 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 by lenses ?* Yes No Since what year ?* Specify*063 - Do you have difficulty distinguishing colors? (including colour-blindness)* Yes No PULMONARYHAVE YOU SUFFERED OR ARE YOU SUFFERING FROM :038 - Chronic bronchitis ?* Yes No Specify*037 - Emphysema ?* Yes No Specify*036 - Asthma ?* Yes No Specify*007 - Do you suffer from any from a lung disease?* Yes No Specify* PULMONARYOVER THE PAST YEAR, HAVE YOU SUFFERED FROM079 - Shortness of breath with light effort ?* 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 Parkinson disease?* Yes No Since what year ?* Specify*008 - Do you suffer of epilepsy?* Yes No Since what year?* Specify* ILLNESSESDO YOU SUFFER OR HAVE SUFFERED DURING THE LAST YEAR : :112 - From a disease affecting the mobility/locomotive system* Yes No Specify* ILNESSES026 - Within the past 5 years, did you suffer from a cardiac disease? If YES, specify.* Oui Non Specify*027 - Do you have acute episodes of venous thrombosis?* Yes No Specify* ILNESSESDO YOU SUFFER OR HAVE SUFFERED FROM :025 - Diabetes ?* Yes No Since what year ?* Specify*017 - Arthritis or arthrosis ?* Yes No Specify* ILNESSESDO YOU SUFFER OR HAVE SUFFERED DURING THE LAST YEAR OF :083 - Significants headaches ?* Yes No At which frequency ?* 086 - Difficulty concentrating ?* Yes No Specify* ALLERGIESDO YOU SUFFER FROM ALLERGIES OR INTOLERANCES TO : :053 - Chemicals ?* Yes No Specify*095 - Metals ?* Yes No Specify* SLEEP DISORDER028 - Do you suffer from narcolepsy?* Yes No SLEEP DISORDERDURING THE LAST YEAR, HAVE YOU SUFFERED FROM :084 - Insomnia ?* Yes No Specify* DRUGS AND ALCOHOL131 - Do you or have you ever used drugs except cannabis?* Yes No Frequency* Specify* MUSCULO-SKELETALAre you :* Right-handed Left-handed MUSCULO-SKELETALDO YOU SUFFER OR HAVE YOU SUFFERED FROM:020 - A herniated disc?* Yes No Specify*021 - A cervical disc?* Yes No Specify*022 - A lombar disc?* Yes No Specify*018 - A sprain?* Yes No Specify*088 - Back pain or difficulty to carry objects?* Yes No Specify* MUSCULO-SKELETALDO YOU SUFFER OR HAVE YOU SUFFERED FROM :015 - Carpal tunnel syndrom?* Yes No Identify which wrist(s)* Right Left Specify*016 - Tendinitis, bursitis, epicondylitis, epitrochleitis?* Yes No Specify* MUSCULO-SKELETALDO YOU HAVE DIFFICULTY :046 - Go up and down stairs?* Yes No Specify*048 - Kneeling or crouch?* Yes No Specify*049 - Maintain your balance?* Yes No Specify* MUSCULO-SKELETALARE YOU LIMITED :089 - As for the weights to be lifted or transported due to 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, elbows, arms or shoulders?* Yes No Specify*124 - Your hands, hips, knees, ankles, feet?* Yes No Specify* MUSCULO-SKELETALDO YOU SUFFER FROM A LOSS OF :050 - Dexterity to the upper limbs?* Yes No Specify*051 - Sensibility to the upper limbs?* Yes No Précisions* MUSCULO-SKELETALDO YOU SUFFER OR HAVE YOU SUFFERED FROM:044 - Any other conditions and, if so, which one?* Yes No Specify* PREVIOUS ILLNESSES AND ACCIDENTSHAVE YOU BEEN ASSIGNED PERMANENT FUNCTIONAL LIMITATIONS THAT WOULD PREVENT YOU FROM WORKING IN THE JOB FOR WHICH YOU ARE APPLYING::031 - Following an occupational disease, an accident at work, an accident in the car, or any other accident or illness?* Yes No In what year ?* Nature of the lesion* Absence from work* Yes No For how long* 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 In what year ?* Nature of the lesion* Absence from work* Yes No For how long ?* 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 In what year ?* Nature of the lesion* Absence from work* Yes No For how long* Have you been on temporary assignment?* Yes No Do you have limitations ?* Yes No Specify the nature of the limitations GENERAL100 - Have you used any medication for any psychological condition within the last 3 years* Yes No Specify032 - Do you suffer from any illness, injury or pain not mentioned in this questionnaire that prevents you from holding the position for which you are applying?* Yes No Specify*033 - Are you currently receiving medical treatment that prevents you from holding the position for which you are applying?* Yes No Specify*034 - Are you currently taking any medications that may reduce your alertness? If YES (Specify)* Yes No Specify035 - Are you currently taking any prescription drugs related to the questions asked in this questionnaire?* Yes No Specify* I. undersigned* Add your first and last timeConfirmations* 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
