Spécifique – Journalier – Anglais Étape 1 sur 24 4% INSTRUCTION The form is sent confidentially to the medical clinic Questionnaire will be revised by clinic staff with you by phone If you have 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 :* What's the company name that you apply for ? CONFIRMATION OF YOUR IDENTIFICATIONLast name* First name* Birth date*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Format 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 size? (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 Specify*070 - Are you waiting for an operation requiring hospitalization?* Yes No Specify OCCUPATIONAL HISTORYDo you have health problems from exposure : :076 - Activities involving repetitive movements?* Yes No Specify075 - Significant physical efforts?* 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*063 - Do you have difficulty distinguishing colors? (including colour-blindness)* Yes No PULMONARYHAVE YOU SUFFERED OR ARE YOU SUFFERING FROM :038 - Chronic bronchitis ?* Yes No Specify*037 - Emphysema ?* Yes No Specify*036 - Asthma* Yes No Specify*007 - Do you suffer from a lung disease?* Yes No Specify* PULMONARYOVER THE PAST YEAR, HAVE YOU SUFFERED FROM :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 the 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* DISEASESDO YOU SUFFER OR HAVE YOU SUFFERED FROM :025 - Do you suffer of diabetes?* Yes No Since what year?* Specify*017 - Arthritis or arthrosis?* 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 MUSCULOSKELETALDO YOU SUFFER OR HAVE YOU SUFFERED FROM :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* MUSCULOSKELETALDO YOU SUFFER OR HAVE YOU SUFFERED FROM :015 - Carpal tunnel syndrom?* Yes No Identify which wrist(s)* Right Left Specify*016 - Tendinitis, bursitis, epicondylitis, epitrochleitis?* Yes No Specify* MUSCULOSKELETALDO YOU HAVE DIFFICULTY :087 - Keep you head straight for a long period of time?* Yes No Specify*046 - Go up and down stairs?* Yes No Specify*048 - Kneeling or crouch?* Yes No Specify*049 - Maintain your balance?* Yes No Specify* MUSCULOSKELETALARE YOU LIMITED :089 - Are you limited on the weights you can lift or carry for medical reasons?* Yes No Specify*019 - In your movements or do you have any other condition?* Yes No Specify MUSCULOSKELETALDO YOU FEEL PAIN WHEN YOU SOLICIT :052 - Your wrists, elbows, arms or shoulders?* Yes No Specify*124 - Your hands, hips, knees, ankles, feet?* Yes No Specify* MUSCULOSKELETALDO YOU SUFFER OR HAVE YOU SUFFERED FROM :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 ACCIDENTSHAVE YOU BEEN ASSIGNED PERMANENT FUNCTIONAL LIMITATIONS THAT WOULD PREVENT YOU FROM WORKING IN THE JOB FOR WHICH YOU ARE APPLYING :031 - 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* 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 Do you have limitations ?* 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* Have you been on temporary assignment?* Yes No Do you have any limitations?* Yes No Describe the nature of the injury GENERAL100 - 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 medication 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*Sans titrePremier choixDeuxième choixTroisième choix Δ
