Spécifique – Journalier Alimentaire – Anglais Étape 1 sur 26 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 that you received* Password* What's the company name that you apply for ? Confirmation de votre identificationLast name* First name* Birth date*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date field format : 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 Night 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 Specify060 - To humidity?* Yes No Specify061 - To cold ?* 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 of double vision?* Yes No 005 - Do you have cataracts ?* 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 from lung disease ?* Yes No Specify* PULMONARYDURANT LA DERNIÈRE ANNÉE, AVEZ-VOUS SOUFFERT :079 - Shortness of breath if light effort ?* 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 Parkinson disease?* Yes No Since what year ?* Specify*008 - Do you suffer of epilepsy ?* Yes No Since what year ?* Specify* DISEASES026 - Within the past 5 years, did you suffer from a cardiac disease? If YES, specify.* Yes No Specify*027 - Do you have acute episodes of venous thrombosis?* Yes No Specify* DISEASESSOUFFREZ-VOUS OU AVEZ-VOUS DÉJÀ SOUFFERT DE :025 - Do you suffer of diabetes ?* Yes No Since what year ?* Specify*017 - Arthritis or arthrosis ?* Yes No Specify*045 - Raynaud’s Phenomenon ?* Yes No ALLERGIES121 - Are you suffering from allergies or intolerance ?* Yes No Specify*Specify*096 -Do you suffer of contact dermatitis ?* Yes No Specify* SLEEP DISORDER028 - Do you suffer from narcolepsy ?* Yes No Since what year ?* Specify*084 - Within the last year, did you suffer from insomnia ?* Yes No At what frequency ?* Specify* DRUGS AND ALCOHOL131 -Do you or have you ever used drugs except cannabis ?* Yes No At what frequency ?* Specify* 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 syndrom ?* Yes No Identify which wrist(s)* Right Left Specify*016 - Tendinitis, bursitis, epicondylitis, epitrochleitis ?* Yes No Specify* MUSCULOSKELETALAVEZ-VOUS DE LA DIFFICULTÉ À :087 - Keep you head straight for a long period of time ?* Yes No Specify*046 - Going up and down stairs ?* Yes No Specify*048 - Kneeling or crouch ?* Yes No Specify*049 - Maintain your balance ?* Yes No Specify* MUSCULOSKELETALÊTES-VOUS LIMITÉ :089 - As for the weights to be lifted or transported due to a medical condition ?* Yes No Specify*019 - In you movements or do you have any other condition ?* Yes No Specify MUSCULOSKELETALRESSENTEZ-VOUS DE LA DOULEUR LORSQUE VOUS SOLLICITEZ :052 - Your wrists, elbows, arms or shoulders ?* Yes No Specify*124 - Your hands, hips, knees, ankles, feet ?* Yes No Specify* MUSCULOSKELETALSOUFFREZ-VOUS OU AVEZ-VOUS DÉJÀ SOUFFERT:050 - Dexterity in the upper limbs ?* Yes No Specify*051 - Sensitivity in the upper limbs ?* Yes No Specify* MUSCULOSKELETALSOUFFREZ-VOUS OU AVEZ-VOUS DÉJÀ SOUFFERT:112 - A disease affecting mobility / locomotor system ?* Yes No Specify*044 - Any other conditions and, if so, which one ?* Yes No Specify* PREVIOUS ILLNESSES AND ACCIDENTSVOUS A-TON ATTRIBUÉ DES LIMITATIONS FONCTIONNELLES PERMANENTES DE NATURE À VOUS EMPÊCHER D’OCCUPER L’EMPLOI POUR LEQUEL VOUS POSEZ VOTRE CANDIDATURE :031 - Following an occupational disease, 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* 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? (2)* Yes No Since what year?* Nature of the injury* Absence from work* Yes No For how long* Have you been on temporary assignment ?* Yes No Have you been on temporary assignment?* Yes No Describe the nature of the limitationsDo you want to report another accident? (3)* Yes No Since what year ?* Nature of the injury* Absence from work* Yes No For how long* Do you have any limitations ?* Yes No Do you have any limitations?* Yes No Describe the nature of the injury GÉNÉRAL100 - Have you used any medication for any psychological condition within the last 3 years ?* Yes No Specify032 - 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 Specify*033 - Are you currently receiving medical treatment that prevents you from holding the position for which you are applying?* Yes No Specify*034 - Are you currently taking any medications that may reduce your alertness? If YES (Specify)* Yes No Specify035 - Are you currently taking any prescription drugs related to the questions asked in this questionnaire?* Yes No Specify* 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. I. undersigned* Add your first and last timeSignature* Δ