P-260 Anglais Étape 1 sur 20 5% 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*Jour12345678910111213141516171819202122232425262728293031Mois123456789101112Année2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Form 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 Best time to contact you* AM PM Evening OCCUPATIONAL HISTORY094 - What is your height?* 093 - What is your weight?* 092 - Are you awaiting an operation or treatment?* Yes No Details070 - Have you ever been hospitalized, operated on or undergone anesthesia?* Yes No Details PRÉSENTEZ-VOUS DES PROBLÈMES DE SANTÉ DÉCOULANT DE L'EXPOSITION :076 - Repetitive movements activites ?* Yes No Details118 - Have you ever done a similar job with another employer?* Yes No ORL001 - Do you suffer from deafness , or hearing problems?* Yes No Since what year ?* Details*004 - Within the last year, have you had any vertigo and, if so, how often?* Yes No How often?* Details*006 - Do you suffer from a decrease in your visual ability not corrected by corrective lenses?* Yes No Since what year ?* Details*063 - Do you have any difficulty distinguishing colors?* Yes No PULMONARYSOUFFREZ-VOUS OU AVEZ-VOUS DÉJÀ SOUFFERT :036 - Asthma?* Yes No Details*007 - Do you suffer from a lung disease?* Yes No Details* NERVOUS SYSTEMNervous System040 - Do you suffer from paralysis?* Yes No Since what year?* Details*008 - Do you suffer of epilepsy?* Yes No Since what year?* Details*SOUFFREZ-VOUS OU AVEZ-VOUS SOUFFERT DURANT LA DERNIÈRE ANNÉE :010 -Of convulsions?* Yes No How often?* Details*011 - Loss of consciousness?* Yes No How often?* Details* ILLNESSES026 - In the past 5 years, have you had any heart problem? If YES (specify) Yes No Details122 - Do you suffer from intestinal problems (ulcerative colitis, etc ...)? Yes No 123 - Do you suffer from memory loss, various emotional problems, depression, psychosis? Yes No 121 - Do you suffer from allergies? Yes No Enter allergies 067 - Do you have difficulty working in closed or confined spaces?* Yes No Details* SOUFFREZ-VOUS OU AVEZ-VOUS DÉJÀ SOUFFERT DE :025 - Do you suffer from diabetes ?* Yes No Since what year?* Details*085 - Do you suffer from anxiety?* Yes No How often?* Details*DURAND LA DERNIÈRE ANNÉE, AVEZ-VOUS SOUFFERT DE:083 - Significant headaches?* Yes No How often?* 086 -Diffculties with concentration ?* Yes No Since what year?* Details* SLEEPING DISORDERHow often?* Details* DRUGS AND ALCOHOL068 -Are you taking or have you taken any drugs? Yes No Details030 - Has a doctor diagnosed you with a substance use disorder (alcohol or drugs)? Have you ever felt the need to change your drinking habits? ** Yes No What year?* Details* MUSCULOSKELETALAre you?* Right-handed Left-handed 120 - Have you had any restrictions, functional limitations or permanent impairment? Yes No Details127 - Do you a know abnormality of the spine? Yes No Details SOUFFREZ-VOUS OU AVEZ-VOUS DÉJÀ SOUFFERT:126 - a "kidney tower", sciatica, "sciatica"? Yes No Details020 - A herniated disc ?* Yes No Details*021 - A cervical disc ?* Yes No Details*022 - A lombar disc ?* Yes No Details*018 - A sprain ?* Yes No Details*125 - Back pain or difficulty bending? Yes No Details016 - Tendonitis, bursitis, epicondylitis, epitrochleitis ?* Yes No Details*044 - Any other condition and, if so, which one ?* Yes No Details*088 - Back pain or difficulty to carry objects ?* Yes No Details* AVEZ-VOUS DE LA DIFFICULTÉ À :087 - Keep you head straight for a long period of time ?* Yes No Details*046 - Go up and down stairs ?* Yes No Details*048 - Kneeling or crouch ?* Yes No Details*023 - Walking on an uneven surface ?* Yes No Details* ÊTES-VOUS LIMITÉ :089 - As for the weights to be lifted or transported due to a medical condition ?* Yes No Details*019 - In you movements or do you have any other condition ?* Yes No Details AVEZ-VOUS DE LA DIFFICULTÉ À EXÉCUTER DES MOUVEMENT OU RESSENTEZ-VOUS DE LA DOULEUR LORSQUE VOUS SOLLICITEZ :052 - Your wrists, elbows, arms or shoulders ?* Yes No Details*124 - Your hands, hips, knees, ankles, feet ? Yes No Details EPIDERMALSOUFFREZ-VOUS DE L’UNE OU L’AUTRE DES ALLERGIES OU INTOLÉRENCES SUIVANTES :055 - Irritating skin products ?* Yes No Details*096 - Contact dermatitis ?* Yes No Under what circumstances ?* PREVIOUS ILLNESSES AND ACCIDENTSAVEZ-VOUS DÉJÀ EU :031 - an occupational disease, work accident, car accident, or other accident or illness?* Yes No In what year ?* Nature of the injury* Absence from work* Yes No For how long* Have you been on temporary assignment ?* Oui Non Do you have any limitations ?* Yes No Describe the nature of the limitationsDo you want to report another accident? (2)* Yes No In what year ?* Nature of the injury* Absence from work* Yes No For how long* Have you been on temporary assignment ?* Yes No Do you have any limitations ?* Yes No Describe the nature of the limitationsDo you want to report another accident? (3)* Yes No In what year ?* Nature of the injury* Absence from work* Yes No For how long* Have you been on temporary assignment ?* Yes No Do you have any limitations ?* Yes No Describe the nature of the limitations GÉNÉRAL119 - Have you consulted or are you currently being followed by a health professional ? No Psychologist Chiropractor Physiotherapist Other Details and frequency ?Details and frequency ?Details and frequency ?Details and frequency ?109 - Have you used any medication for psychological condition in the last 3 years ?* Yes No Details032 - 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 Details*033 - Are you currently receiving medical treatment that prevents you from holding the position for which you are applying?* Yes No Details*034 - Are you currently taking any medications that may reduce your alertness? If YES (Specify)* Yes No Details035 - Are you currently taking any prescribed medication ?* Yes No Details* 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
