P-140 Anglais Étape 1 sur 28 3% 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* Password* QUESTIONNAIRE MÉDICAL PRÉ-EMBAUCHE POUR PF RÉSOLUE :Confirmation for your identificationLast name* First name* Date of birth*Jour12345678910111213141516171819202122232425262728293031Mois123456789101112Année20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Format 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 tittle Disponibilités pour vous joindre* 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 HISTORYPRÉSENTEZ-VOUS DES PROBLÈMES DE SANTÉ DÉCOULANT DE L'EXPOSITION :076 - Activities involving repetitive movements?* Yes No Specify075 - Significant physical efforts?* Yes No Specify071 - Vibratory tools?* Yes No Specify OCCUPATIONAL HISTORYPRÉSENTEZ-VOUS DES PROBLÈMES DE SANTÉ DÉCOULANT DE L'EXPOSITION :060 - To humidity ?* Yes No Specify061 - To cold ?* Yes No Specify062 - To heat ?* Yes No Specify072 - Dust, stripping, sandblasting, wood drilling, carbon, etc.* Yes No Specify073 - Irritating skin products ?* Yes No Specify074 - Chemical products, paint, etc.* 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* OPHTALMOLOGIC006 - Do you suffer from a decrease in your visual ability that is not corrected ?* Yes No Since what year ?* Specify*003 - Do you suffer from double vision?* Yes No 063 - Do you have difficulty distinguishing colors? (including colour-blindness)* Yes No PULMONARYSOUFFREZ-VOUS OU AVEZ-VOUS DÉJÀ SOUFFERT :038 - Chronic bronchitis ?* Yes No Specify*037 - Emphysema ?* Yes No Specify*036 - Asthma ?* Yes No Specify*007 - Do you suffer from any form of lung disease ?* Yes No Specify* PULMONARYDURANT LA DERNIÈRE ANNÉE, AVEZ-VOUS SOUFFERT :079 - Shortness of breath to light effort ?* Oui Non 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 Parkinsons disease?* Yes No Since what year?* Specify*008 - Do you suffer from epilepsy?* Yes No Since what year ?* Specify* NERVOUS SYSTEMDURAND LA DERNIÈRE ANNÉE, AVEZ-VOUS DÉJÀ SOUFFERT DE :010 -From convulsions ?* Yes No Specify*011 - Lost of consciousness ?* Yes No Specify* DISEASES026 - Within the past 5 years, did you suffer from a cardiac disease? If YES, specify.* Yes No Specify*067 - Do you have difficulty working in enclosed or confined spaces?* Yes No Specify* DISEASESSOUFFREZ-VOUS OU AVEZ-VOUS DÉJÀ SOUFFERT DE :025 - Do you suffer from diabetes ?* Yes No Since what year ?* Specify*017 - Arthritis or arthrosis ?* Yes No Specify*045 - Raynaud’s Phenomenon ?* Yes No 081 - Do you suffer from hemophila ?* Yes No 085 - Do you suffer from anxiety ?* Yes No Specify* DISEASESDURAND LA DERNIÈRE ANNÉE, AVEZ-VOUS DÉJÀ SOUFFERT DE :083 - Severe headaches ?* Yes No Specify* ALLERGIES121 - Do you have any allergies or intolerances ?* Yes No Specify* ALLERGIESSOUFFREZ-VOUS D'ALLERGIES :077 - To bees ?* Yes No 078 - Seasonal allergies ?* Yes No SLEEP DISORDER084 - In the past year, have you suffered from insomnia?* Yes No At what frequency ?* Specify* DRUGS AND ALCOHOL068 - Do you or have you ever used drugs?* Yes No Frequency* Specify*030 - Have you ever been diagnosed with a substance use disorder (Alcohol or drugs) by a doctor?* Yes No In what year?* Identify the substance :* Drugs - Cannabis Drugs - Other Alcohol MUSCULOSKELETALAre you :* Right-handed Left-handed MUSCULOSKELETALSOUFFREZ-VOUS OU AVEZ-VOUS DÉJÀ SOUFFERT: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* MUSCULOSKELETALSOUFFREZ-VOUS OU AVEZ-VOUS DÉJÀ SOUFFERT:015 - Carpal Tunnel Syndrome?* Yes No Specify*016 - Tendonitis, bursitis, epicondylitis, epitrochleitis ?* Yes No Specify* MUSCULOSKELETALAVEZ-VOUS DE LA DIFFICULTÉ À :087 - Keeping your head straight for a long period of time ?* Yes No Specify*046 - Walking up or down a staircase?* Yes No Specify*048 - Kneeling or squatting?* Yes No Specify*049 - Maintaining your balance ?* Yes No Specify*023 - Walking on an uneven surface?* Yes No Specify*047 - Working in heights (platform, stool, ladder )?* Yes No From what height ?* MUSCULOSKELETALÊTES-VOUS LIMITÉ :089 - On the weight you can lift or carry because of a medical reason?* Yes No Specify*019 - In your mouvements or do have have any other condition?* Yes No Specify MUSCULOSKELETALRESSENTEZ-VOUS DE LA DOULEUR LORSQUE VOUS SOLLICITEZ :052 - Your wrists, your elbows, your arms or your shoulders?* Yes No Specify*124 - Your hands, your hips, your knees, your ankles or feet?* Yes No Specify* MUSCULOSKELETALSOUFFREZ-VOUS OU AVEZ-VOUS DÉJÀ SOUFFERT:112 - a disease that affects your mobility/ locomotor system?* Yes No Specify*044 - Any other conditions and, if so, which one ?* Yes No Specify* PREVIOUS ILLNESSES AND ACCIDENTS031 - Following an occupational disease, an accident at work, an accident at work, an accident in the car, or any other accident or illness?* Yes No Since what year ?* Nature of the injury* Absence from work* Yes No For how long* Do you have any limitations ?* Yes No Describe the nature of the limitationsDo you want to report another accident? (2)* Yes No What year ?* Nature of the injury* Absence from work* Yes No For how long* Do you have any limitations ?* Yes No Describe the nature of the limitations GENERAL100 - Have you used medication for a psychological condition in the last 3 years?* Yes No Specify032 - Do you suffer from any illness, injury or pain not mentionned in this questionnaire that would prevent you from occupuying the position for which you are applying?* Yes No Specify*033 - Are you currently receiving medical treatment that prevents you from occupying the position for which you are applying?* Yes No Specify*034 - Are you currently taking any medications that could reduce your alertness? If YES (Specify)* Yes No Specify035 - Are you currently taking any prescription medications 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
