S-170 English Étape 1 sur 31 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 f 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* Confirmation of 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 (2) Job title Best time to contact you* AM PM Evening OCCUPATIONAL HISTORY094 - What is your height? (indicate: meters or feet)* 093 - What is your weight? (Indicate: pounds or kilograms)* 070 - Are you awaiting for an surgery requiring hospitalization?* Yes No Specify041 - Have you ever surgery with the exception of an esthetic or gynecological operation?* Yes No Specify OCCUPATIONAL HISTORYDo you have health problems from exposure : :076 - Activities involving repetitive movements ?* Yes No Specify075 - Significant efforts* Yes No Specify ENT001 - Do you suffer from deafness (hearing loss) ?* Yes No Since what year ?* Specify*039 - Do you suffer from discharges or buzzing noises in your ears?* Yes No Specify*002 -Do you have a decrease in your peripheral vision?* Yes No Specify*004 - In the last year have you suffered from vertigo?* Yes No Specify* VISION003 - Do you suffer from double vision?* Yes No Since what year ?* Specify*006 - Do you suffer from a decrease in your visual ability that is not corrected with glases?* Yes No Since what year ?* Specify*090 - Do you have a decrease in your peripheral field of vision?* Yes No Since what year ?* Specify* PULMONARYDO YOU SUFFER OR HAVE YOU SUFFERED :038 - Chronic bronchitis?* Yes No Specify*037 - Emphysema ?* Yes No Specify*036 - Asthma* Yes No Specify* PULMONARY007 - Do you suffer from a lung disease?* Yes No Specify* PULMONARYDURING THE LAST YEAR, HAVE YOU SUFFERED :079 -Do you suffer from shortness of breath doing mild exertion ?* Yes No Specify* NERVOUS SYSTEM009 -Do you suffer from a tremor disorder ?* Yes No Specify*008 - Do you suffer from epilepsy ?* Yes No Since what year ?* Specify*112 - From a disease affecting mobility/locomotor system ?* Yes No Specify* NERVOUS SYSTEMDO YOU SUFFER OR HAVE SUFFERED DURING THE LAST 3 YEAR :012 - Dizziness?* Yes No Specify*011 - Lost of consciousness?* Yes No Specify*010 - Convulsions?* Yes No Specify* ILLNESSES081 - Do you suffer from hemophilia?* Yes No Specify*026 - In the past 5 years, have you suffered from a cardiac condition? If YES (specify)* Yes No Specify* ILNESSESDO YOU SUFFER OF HAVE YOU SUFFERED :045 - Raynaud's Phenomenon?* Yes No Specify*083 - Significant headaches?* Yes No Specify*097 - Are you insulin-dependent? diabetes?* Yes No Since what year ?* Specify* ILLNESSES098 - Have you ever been banned from working at night by your doctor ?* Yes No Specify* ALLERGY059 - Are you suffering from an allergy or intolerance to dust ?* Yes No Specify*077 - Do you suffer from a bee allergy?* Yes No Specify*096 - Contact dermatitis?* Yes No Specify*078 - Seasonal?* Yes No Specify*058 - Latex?* Yes No Specify*057 - To frequent hands washing or prolonged contact with liquids, skin irritants?* Yes No Specify*055 - Irritating skin products?* Yes No Specify*053 - Chemical products?* Yes No Specify*095 - Metals?* Yes No Specify* SLEEP DISORDER029 - Do you suffer from sleep apnea?* Yes No Specify*028 - Do you suffer of narcolepsy ?* Yes No Since what year ?* Specify*084 - During the last 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 Specify*102 - Are you or have you been treated for a substance abuse discorder ?* Yes No Frequency* Specify* MUSCULO-SKELETALAre you :* Right-handed Left-handed MUSCULO-SKELETALDO YOU SUFFER OR HAVE YOU SUFFERED :021 - Cervical disc ?* Yes No Specify*022 - Lombar disc ?* Yes No Specify*129 - Back pains?* Yes No Specify* MUSCULO-SKELETALDO YOU SUFFER OR HAVE YOU SUFFERED :087 - Pain from keeping your head still for long periods of time?* Yes No Specify*128 - Paralysis in your upper or lower limbs?* Yes No Specify* MUSCULO-SKELETAL252 -Do you feel discomfort, weakness or pain when you solicit you wrists, your elbows, your arms or your shoulders ?* Yes No Specify*124 - Do you have pain when you solicit: Your hands, hips, knees, ankle, feet?* Yes No Specify* MUSCULO-SKELETALDO YOU SUFFER OR HAVE YOU SUFFERED :088 - Back pain or difficulty transporting objects?* Yes No Specify* MUSCULO-SKELETALDO YOU SUFFER OR HAVE YOU SUFFERED :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 - Arthiritis or osteoarthritis ?* Yes No Specify*023 - Walking on an uneven surface?* Yes No Specify*019 - Are you limited in your movements due to any other medical condition?* Yes No Specify* MUSCULO-SKELETALARE YOU LIMITED :089 - Are you limited on the weight you can lift or carry due to a medical condition ?* Yes No Specify* MUSCULO-SKELETAL044 - Are your limited in your movements due to any other condition ?* Yes No Specify PREVIOUS DISEASES AND ACCIDENTSHAVE YOU BEEN DIAGNOSED WITH PERMANENT FUNCTIONNAL LIMITATIONS :031 - After an occupational disease, work accident, car accident, or other accident or illnesses?* Yes No In what year ?* Nature of the lesion* Medical leave?* Yes No How much time* Were you put on light work?* Yes No Do you have limitations ?* Yes No Specify the nature of the limitationsDo you want to report another accident? (2)* Yes No Since what year ?* Nature of the lesion* Medical leave?* Yes No How much time ?* Were you put on light work?* Yes No Do you have 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* Medical leave?* Yes No How much time ?* Were you put on light work?* Yes No Do you have limitations ?* Yes No Specify the nature of the limitations GENERAL032 - Are you suffering from any illness, injury or pain not mentioned in this questionnaire that would prevent you from occupying the position you are applying for?* Yes No Specify*033 - Actually, are you undergoing any medical treatments that would prevent you from occupying the position you are applying for? * Yes No Specify*035 - Are you currently taking any medications that may decrease your alertness?* Yes No Specify* GENERAL100 - Have you used, in the last 3 years, medication for a psychological condition ?* Yes No Specify034 - Are you currently taking any medications that may decrease your alertness ?* Yes No Specify* GENERALFemale only, in accordance with preventive withdrawal program and shift longer than 10 hours :099 - Are you more than 10 weeks pregnant?* Yes No I'm a men Specify* 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