Spécifique – SAC – Anglais Étape 1 sur 15 6% Instruction The form is forwarded under confidential cover to the medical clinic.. A review of the questionnaire will be done by the clinic staff with you by phone If you have any difficulties or think that you may need a reader, you can call us anytime at 1 (877) 606-8111 (toll free number). Enter the ID number you received* Password* What's the name of the compagny that you apply for ? Confirm identificationLast name* First Name* Date of Birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Format for date : dd/mm/yyyyProvince*AlbertaColombie-BritanniqueManitobaNouveau-BrunswickTerre-Neuve et LabradorTerritoires du Nord-OuestNouvelle-ÉcosseNunavutOntarioÎle du Prince-ÉdouardQuébecSaskatchewanYukonE-mail Phone 1*Phone 2Job Title Best time to contact you* AM PM SOIR - Evening OCCUPATIONAL HISTORY041 - Have you undergone any operation that has caused a reduction in your physical capacity, with the exception of cosmetic or gynecological surgery?* Yes No Details070 - Are you waiting for a surgery requiring hospitalization?* Yes No Details ORL001 - Do you suffer from deafness (hearing loss or defects)?* Yes No Since what year ?* Details*006 - Do you suffer from a decrease in visual ability that is not corrected by corrective lenses (glasses, contact lenses)?* Yes No Since what year?* Details* NERVOUS SYSTEM209 - Do you have a tremor problem?* Yes No Since what year?* Details* ILLNESSESDURING THE LAST YEAR, HAVE YOU SUFFERED FROM:083 - Significant headaches ?* Yes No How often ?* 086 - Difficulty concentrating?* Yes No Since what year ?* Details* MUSCULO-SKELETALAre you?* Right-handed Left-handed DO YOU SUFFER OR HAVE YOU EVER SUFFERED :021 - Cervical hernia?* Yes No Details*022 - Lumbar hernia?* Yes No Details*Identify the wrist(s)* Right Left Details* MUSCULO-SKELETALDO YOU SUFFER OR HAVE YOU EVER SUFFERED FROM::015 - Carpal tunnel syndrome (repetitive movement limitation, awkward wrist position)?* Yes No Details*016 - Tendinitis, bursitis, epicondylitis, epitrochleitis?* Yes No Details*017 - Arthritis or arthrosis?* Yes No Details*019 - Any other condition and, if applicable, which one?* Yes No Details* MUSCULO-SKELETALDO YOU SUFFER OR HAVE YOU EVER SUFFERED FROM::129 - Back pains ?* Yes No Details*128 - Paralysis of the upper limbs?* Yes No Details*DO YOU HAVE ANY DIFFICULTIES :087 - Maintaining your head straight for long periods of time ?* Yes No Details* MUSCULO-SKELETALDO YOU FEEL PAIN WHEN YOU SOLICIT :252 - Your wrists, elbows, arms, hands or shoulders?* Yes No ILLNESSES AND PREVIOUS ACCIDENTSHAVE YOU BEEN DIAGNOSED WITH PERMANENT FUNCTIONNAL LIMITATIONS THAT WOULD PREVENT YOU FROM OCCUPYING THE EMPLOYEMENT FOR WHICH YOU ARE APPLYING? :031 - Following an occupational disease, accident at work, car, or other accident or illness?* Yes No In which year?* Nature of the injury?* Did you miss work?* Yes No For how long?* Where you on temporary assignment ?* Yes No Do you have any functional limitations?* Yes No Specify the nature of the limitationsDo you want to report another accident? (2)* Yes No In which year ?* Nature of the injury* Did you miss work?* Yes No For how long?* Have you been on temporary assignment?* Yes No For how long?* Yes No Specify the nature of the limitationsDo you want to report another accident? (3)* Yes No In which year ?* Nature of the injury* Did you miss work?* Yes No For how long?* Do you have any limitations?* Yes No Avez-vous des limitations ?* Oui Non Spêcify the nature of the limitations? DRUGS AND ALCOHOL102 - Are you or have you been treated for a drug or alcohol use disorder?* Yes No GENERAL032 - Are you suffering from any illness or injury not mentioned in this questionnaire that could prevent you from occupying the postion you are applying for?* Yes No If so , specify*033 - Are you suffering from an illness or injury that would prevent you from occupying the position you are applying for?* Yes No Details*034 - Are you currently taking any medication that could impair your ability to concentrate? If YES (Specify)* Yes No Details*035 - Are you currently taking prescription medication related to the questions asked in this questionnaire?* Yes No Details* I, the undersigned* Add full nameConfirmation* I declare that the answers provided in this medical questionnaire are accurate and complete. I acknowledge that SECURIMED 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 SECURIMED will provide the applicant with a report containing only its conclusions regarding the compatibility of my health with the requirements of the position. This report, excluding any detailed medical information, will be shared in compliance with privacy laws and I understand that this report will belong to the latter and that any request for a copy must be addressed to him. Lastely, I recognize that my answers will be used to determine whether my health condition prevents me from occupying the position applied for, and, therefore, I am aware that giving false or misleading information could justify the applicant not to hire me or invalidate the terms of my employment. 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
