Q: S-130 Bureau – Anglais Étape 1 sur 11 9% Instruction The form is forwarded under confidential cover to the medical clinic. If necessary, upon receipt of the document, a nurse of our clinic will communicate with you directly by phone to review the questionnaire. If you are having problems reading this document or think you need help, you may call us anytime toll free at : 1 (877) 606-8111 Enter the identification number you received* Password* Confirmation of your identificationName* Surname* Date of birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Format date field : dd/mm/yyyyProvince*AlbertaColombie-BritanniqueManitobaNouveau-BrunswickTerre-Neuve et LabradorTerritoires du Nord-OuestNouvelle-ÉcosseNunavutOntarioÎle du Prince-ÉdouardQuébecSaskatchewanYukonE-mail Telephone 1*Telephone 2Job tittle Best time to contact you* AM PM SOIR - Evening ENT150 - Do you have a vision problem that prevents you from doing the specific job for which you are applying?* YES NO Details*001 - Do you suffer from deafness ( hearing loss or defects)?* YES NO Since what year?* Details* NERVOUS SYSTEM008 - Do you suffer from epilepsy?* YES NO Since what year?* Details* DISEASESARE YOU SUFFERING OR HAVE ALREADY SUFFERED :028 - Narcolepsy?* Yes No Since what year?* Details*084 - A sleeping disorder?* YES NO Details* MUSCULOSKELETALARE YOU LIMITED IN YOUR MOVEMENTS :Details*Identify the wrist (s)* Right Left Details*016 Tendinitis, bursitis, epicondylitis, epitrochleitis?* Yes No Details*017 Arthritis or osteoarthritis?* YES NO Detail*044 Any other condition and, if so, which?* YES NO Details* MUSCULOSKELETALRFEEL PAIN WHEN YOU SOLICIT :052 Your wrists, elbows, arms, or shoulders?* YES NO Details* EPIDERMALDO YOU SUFFER FROM ANY OF THE FOLLOWING ALLERGIES OR INTOLERENCES :096 - Contact dermatitis ?* YES NO Details*059 Dust?* YES NO Details* PREVIOUS DISEASES AND ACCIDENTSHAVE YOU BEEN DIAGNOSED WITH PERMANENT FUNCTIONAL LIMITATIONS THAT PREVENT'S YOU FROM OCCUPYING THE EPOSITION THAT YOU ARE APPLYING FOR::031 - Following an occupational disease, accident at work, car, or other accident or illness?* Yes NO Since what year?* Nature of the injury* Sick Leave* YES NO For how long* Have you been on temporary assignment?* YES NO Do you have any limitations?* YES NO Specify the nature of the limitationsDo you want to report another accident? (2)* YES NO Since what year?* Nature of the injury* Sick Leave* YES NO For how long* Have you been on temporary assignment ?* YES NO Do you have any 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* SIck Leave* YES NO For how long* Have you been on temporary assignment ?* YES NO Do you have any limitations ?* YES NO Specify the nature of the limitations GENERAL032 - Do you suffer from an illness, injury or pain not mentioned in this questionnaire that prevents you from occupying the position you are applying for?* YES NO Specify*033 - Are you currently receiving medical treatment that prevents you from occupying the position your applying for?* YES NO Specify*035 -Are you currently taking any prescribed medication related to the previous questions of this questionnaire?* YES NO Specify*034 -Are you currently taking any medications that may decrease your alertness? IF YES Specify YES NO Specify I, the undersigned:* Ajouter votre Nom et Prenom.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 responses 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 and, therefore, I acknowledge that giving false or misleading information could justify the applicant's not hire me or cause me to break my employment relationship. Signature* Δ
