Stornoway Health English

Last Name

First Name

Cellular

Date of Birth

Health Insurance Number

Address

Email Address

Position for which you have applied

Department for which you will work

Do you take prescription drugs on a regular basis?

No
Yes

Specify

Do you drink alcohol?

No
Yes

Specify the frequency

Do you use drugs or any other hallucinogenic substances?

No
Yes

Specify the frequency

Are you taking any over-the-counter medications?

No
Yes

Specify

Name of family doctor

Date of last dose of Tetanus Vaccine

Date of last annual physical

Date of last medical consultation:

Reason

Height

Weight

High blood pressure

No
Yes

Angina / Chest pain

No
Yes

Heart attack

No
Yes

Cerebrovascular accident (Stroke)

No
Yes

Blood circulation disorder / Coagulation

No
Yes

Cardiac palpitation (Arythmia)

No
Yes

Other

No
Yes

Specify

Asthma / Emphysema / Chronic bronchitis

No
Yes

Sleep apnea

No
Yes

Pneumonia

No
Yes

Other

No
Yes

Specify

Arthritis / Rheumatoid arthritis / Osteoarthritis

No
Yes

Tendinitis / Bursitis (shoulder, elbow, etc.)

No
Yes

Carpal Tunnels / Raynaud’s Disease

No
Yes

Disk herniation

No
Yes

Sprains (ankle, back, wrists, etc.)

No
Yes

Fracture / amputation / dislocation

No
Yes

Other

No
Yes

Specify

Diabetes

No
Yes

Gastric reflux / heartburn / ulcers

No
Yes

Anxiety / Depression / Bipolarity / ADHD

No
Yes

Epilepsy

No
Yes

Thyroid disorders

No
Yes

Kidney disease / Kidney stone

No
Yes

Liver disease / Gallbladder stone

No
Yes

Cancer

No
Yes

Abdominal / Hiatal / Inguinal hernia

No
Yes

Migraine

No
Yes

Dizziness / Labyrinthitis

No
Yes

Visual impairment

No
Yes

Hearing impairment

No
Yes

Other

No
Yes

Specify

Have you ever had surgery?

No
Yes

Specify (what year)

Have you ever had a work accident?

No
Yes

Is your file consolidated with the CNESST?

No
Yes

Date of the event

The clinic is open from 6:00 am to 6:00 pm. After regular business hours, the staff is on call for EMERGENCY ONLY.

I UNDERSTAND

You must bring your own personal medication: allow at least 7 more days in case of a change in your schedule.

I UNDERSTAND

Any personal condition must be taken care of and controlled BEFORE you enter the site, failing which you will be returned home.

I UNDERSTAND

The Health Service is not a pharmacy: You are responsible for bringing your own personal hygiene products and a basic medication kit (Tylenol, Advil, hand cream, lip balm, etc.).

I UNDERSTAND

No medication will be given without prior consultation with clinic staff.

I UNDERSTAND

Any workplace accident must be reported to the supervisor and an accident report completed at the health unit no later than the end of the shift.

I UNDERSTAND

All personal information contained in this form may be shared with any other SWY health professional and/or human resources personnel when necessary.

I UNDERSTAND

I certify that the information contained in this form is accurate and that a false statement could lead to consequences that could include the loss of my employment with Stornoway.

I declare that I understand the physical and mental demands of the job for which I have applied and that I am able to perform the job without putting my health and physical integrity at risk.

Do you have any allergies / intolerances to any medication

No
Yes

Specify

Do you have any food allergies / intolerances?

No
Yes

Specify

Full name

Relationship

Phone number

CANDIDATE IDENTIFICATION

MEDICAL HISTORY

CARDIOVASCULAR SYSTEM

RESPIRATORY SYSTEM

MUSCULOSKELETAL SYSTEM

OTHER SYSTEMS

SURGERIES

WORK ACCIDENT

HEALTH SERVICE REGULATIONS

SUPPLEMENT TO THE PRE-EMPLOYEMENT DECLARATION

EMERGENCY CONTACT