O-120 Anglais Étape 1 sur 12 8% Instruction Le formulaire est acheminé confidentiellement à la clinique médicale. Une révision du questionnaire sera effectuée par le personnel de la clinique avec-vous par téléphone Si vous avez de la difficulté ou pensez avoir besoin d’un lecteur, vous pouvez nous téléphoner en tout temps au 1 (877) 606-8111 (numéro sans frais). Enter the identification number you received* The password* Confirmation for 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 2Job title Is this post for the pork production division ?* Yes No I don't know Best time to contact you :* AM PM SOIR - Evening ORL063 Do you have difficulty distinguishing colors ?* Yes No Sans titre* 001 do you suffer from hearing loss ?* Yes No Since what year ?* Specify*039 Do you suffer from discharge, buzzing noises ?* Yes No Since what year ?* Specify*004 Within the last year, did you suffer from vertigo ? If so, specify the frequency.* Yes No At which frequency ?* Specify* PULMONARYHAVE YOU SUFFERED OR ARE YOU SUFFERING FROM :038 Chronic bronchitis ?* Yes No Specify*037 Emphysema ?* Yes No Specify*036 Asthma ?* 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*DO YOU SUFFER OR HAVE YOU SUFFERED FROM :010 Lost of consciousness or convulsions ?* Yes No Frequency* Specify*012 Diziness ?* Yes No Frequency* Specify* ILLNESSESDO YOU SUFFER OR HAVE YOU EVER SUFFERED OF :028 Narcolepsy ?* Yes No Since what year ?* Specify*043 Diabetes with a necessity of always having food on you ?* Yes No Since what year ?* Specify* MUSCULO-SKELETALAre you :* Right-handed Left-handed ARE YOU LIMITED IN YOUR MOVEMENTS BECAUSE OF :020 Herniated disc ?* Yes No Specify*021 Cervical disc ?* Yes No Specify*022 Lombar disc ?* Yes No Specify*018 A sprain* Yes No Specify*015 Carpal tunnel syndrome ?* Yes No Identify the wrist(s)* Right Left Specify*016 Tendinitis, bursitis, epicondylitis (tennis elbow), epitrochleitis ?* Yes No Specify*017 Arthritis or arthrosis ?* Yes No Specify*044 Any other condition ?* Yes No Specify*HAVE YOU SUFFERED OR ARE YOU SUFFERING FROM :045 Raynaud's Phenomenon ?* Yes No Specify*DO YOU HAVE DIFFICULTY :046 Going up and down stairs ?* Yes No Specify*047 Work at heights (platform, sttol, ladder) ?* Yes No Specify*048 Kneeling or crouch ?* Yes No Specify*049 Keep your balance ?* Yes No Specify*DO YOU SUFFER FROM A LOSS OF :050 Dexterity in the upper or lower limbs ?* Yes No Specify*051 Sensitivity in the upper or lower limbs ?* Yes No Specify*ARE YOU LIMITED :089 On the weight you can lift or carry because of a medical condition ?* Yes No Specify*DO YOU FEEL PAIN WHEN YOU SOLICIT :052 Your wrists, your elbows, your arms or your shoulders ?* Yes No Specify* ÉPIDERMALARE YOU SUFFERING FROM ANY OF THE FOLLOWING ALLERGIES OR INTOLERANCE :054 Pork or poultry ?* Yes No Specify*053 Chemicals ?* Yes No Specify*055 Irritating skin products ?* Yes No Specify*056 Contact dermatitis (pork or poultry) ?* Yes No Specify*057 Frequent hand washing or extended contact with liquids ?* Yes No Specify*058 Latex?* Yes No Specify*059 Dust ?* Yes No Specify* GÉNÉRALDO YOU HAVE HEALTH PROBLEMS FROM EXPOSURE TO :060 Humidity ?* Yes No Since what year ?* Specify061 To cold ?* Yes No Since what year ?* Specify062 To heat ?* Yes No Since what year ?* Specify ILNESSES AND PREVIOUS ACCIDENTSHAVE YOU BEEN DIAGNOSED WITH PERMANENT FUNCTIONAL LIMITATIONS :031 After an occupational disease, work accident, car accident, or other accident or illnesses ?* Yes No Since what year ?* Nature of the lesion* Work stopping ?* Yes No How much time ?* Have you been in temporary assignment ?* Yes No Do you have limitations ?* Yes No Specify the nature of the limitationsDo you wanna report another accident ? (2)* Yes No Since what year ?* Nature of the lesion* Work stopping ?* Yes No How much time ?* Have you been in temporary assignment ?* Oui Non Do you have limitations ?* Yes No Specify the nature of the limitationsDo you wanna report another accident ? (3)* Yes No Since what year ?* Nature of the lesion* Work stopping ?* Yes No How much time ?* Have you been in temporary assignment ?* Yes No Do you have limitations ?* Yes No Specify the nature of the limitation OTHERS032 Are you suffering from any ilness, injury or pain not mentioned in this questionnaire that enables you to occupy the position you are applying for ?* Yes No Specify*033 Are you actually undergoing any medical treatments that enables you to occupy the position you are applying for ?* Yes No Specify*035 Are you currently taking any prescribed medication related to the previous questions in this questionnaire ?* Yes No Specify*Do you have difficulty distinguishing colors ? 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
