Medical Questionnaire Sample Clauses

Medical Questionnaire. If an employee fails to enrol in the Plan within thirty-one (31) days after the date he/she becomes eligible to do so, he/she must complete a medical questionnaire for approval by the Plan Administrator.
Sample 1
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Medical Questionnaire. Please fill in this questionnaire and return it to the employer. All information will be treated as confidential and will be destroyed at the end of the Production. The information requested will enable the employer to take better care of all employees. NAME: ADDRESS: TELE. NO.: MOBILE NO.: AGE: BLOOD TYPE: NEXT OF KIN: DOCTOR: ADDRESS: ADDRESS: TELE. NO.: TELE. NO.: ANY ALLERGIES? YES / NO If yes, please detail any allergies to drugs including drugs such as penicillin, sedatives, antihistamines, aspirin, etc. Please detail any allergies to other substances including food allergies, allergies to stings (eg, bees, wasps), animals (eg, cats) and environmental allergies (eg, dust mites, pollens, grass seeds). Please note symptoms and preferred method of treatment. ANY PHYSICAL DISABILITIES OR PRE-EXISTING MEDICAL CONDITIONS? YES / NO If yes, please provide details (eg, diabetes, asthma, back problems, epilepsy, history of heart problems, pregnancy) EYESIGHT/HEARING - Please provide details if you have impaired eyesight and/or hearing: Do you wear glasses/contact lenses/hearing aid? Do you have specific eyesight problems (eg night blindness, colour blindness, history of recurrent conjunctivitis)? SPECIAL DIETARY REQUIREMENTS? eg, vegetarian, no milk products or other. HAVE YOU HAD A TETANUS INJECTION IN THE LAST FIVE YEARS? YES / NO ARE YOU ON ANY REGULAR MEDICATION AT THIS TIME? YES / NO If yes, please detail Signed by the employee .................................................................................
Sample 1

Related to Medical Questionnaire

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  • Conflict of Interest Questionnaire - Form CIQ No response Do not upload this form unless you have a reportable conflict with TIPS. There is an Attribute entitled “Conflict of Interest Questionnaire Requirement” immediately followed by an Attribute entitled “Conflict of Interest Questionnaire Requirement – Form CIQ – Continued.” Properly respond to those Attributes and only upload this form if applicable/instructed. If upload is required based on your response to those Attributes, the Conflict of Interest Questionnaire – Form CIQ must be downloaded from the “Attachments” section of the IonWave eBid System, reviewed, properly completed, and uploaded at this location. Vendor’s Warranties, Terms, and Conditions (Supplemental Vendor Information Only)

  • Conflict of Interest Questionnaire Requirement Vendor agrees that it has looked up, read, and understood the current version of Texas Local Government Code Chapter 176 which generally requires disclosures of conflicts of interests by Vendor hereunder if Vendor:

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