Employment Medical Questionnaire

To start the assessment process, please fill out as much information as possible on the following form.

Please provide as much detail as possible for all “yes” answers. Please specify dates of illness/injury/surgery/medical condition as well as recovery dates and if you are currently being affected by these conditions. Our medical team will review all affirmative answers with you during your visit.

PATIENT INFORMATION

The purpose of this medical exam is to ensure that your health meets the requirements of the position you are applying for as well as enabling you to carry out the regular duties of the job you are applying for. If at any point you have questions about this form, please contact our team in person or contact our clinic.

Patient Name

First Name

Last Name

Gender

Male

Female

Other

Address

Email Address

Home Phone

(###)

###

####

Family Doctor (if you have)

Family Doctor Phone Number

INJURY INFORMATION

Please provide as much information about the injury as possible.

Injury Date

MM

DD

YYYY

Nature of Injury

Occupation and Industry of the Patient

REFERRAL INFORMATION

If you were referred by an employer, insurer, legal firm, or are referring on behalf of another individual, please indicate below.

Referral Company

Referral Name

First Name

Last Name

Email Address

Phone Number

(###)

###

####

Additional Notes

Our Office

#102 - 12565 88th Avenue
Surrey, BC, V3W 3J7
Canada

(604) 593 0983