Confidential HEALTH QUESTIONNAIRE （Expatriate/FPE) Date ：

YY MM DD

Name: ____________________________________________________ Date of Birth (Age: ______ )

Family Name, First Name & Middle Name YY MM DD □ Male / □ Female

Employee Code:_________________ Ext. No.:_____________ Home Phone:________________________ Location:_________

Dept. : ______________________ Job Title : ____________________ Major Roles: _______________________________________

Kind of Work and Work Condition

#1-1 Have you ever engaged in work handling the following substances and/or requiring the following medical screenings? □Yes □No
□ Dust □ Hazardous chemicals □ AGM □ Enzymes
□ Noise (85dB<) □ Radio active materials □ Biohazardous materials □ Others：

Medical History & Family History

#2-1 Have you ever needed more than a week away from work and a doctor’s care as a result of illness, injury or accident? □Yes □No
#2-2 Have you had the following conditions --------------------------------------------------------------------------------------------- □Yes □No
□ Hypertension □ Diabetes □ Hyperlipemia □ Liver D. □ Heart D. □ Stroke
□ Respiratory D. □ Renal D. □ Prostate/Urinary tract D. □ Anemia □ Tuberculosis □ Cancer
□ Near sighted vision □ Far sighted vision □ Eye trouble □ Hearing D. □ Psychosomatic D. □ Autonomic imbalance
□ Epilepsy □ Emotional Illness □ Neuromuscular D. □ Peptic ulcer □ Arthritis □ Back problems
□ Blood transfusion □ Allergy □ Other: if yes, what?
Please explain details of all “Yes” answers to the
above #2-1～2questions (Use extra paper if needed)： ________________________________________________________________
#2-3 Medical history of you blood relationship families? (D. = Diseases / Disorders)
Father/Mother --- □ Hypertension □ Diabetes □ Hyperlipemia □ Liver D. □ Heart D. □ Stroke □ Cancer □ Others:
Grand father/mother □ Hypertension □ Diabetes □ Hyperlipemia □ Liver D. □ Heart D. □ Stroke □ Cancer □ Others:
Brother/Sister --- □ Hypertension □ Diabetes □ Hyperlipemia □ Liver D. □ Heart D. □ Stroke □ Cancer □ Others:

Present Health Condition

#3-1 Are you taking any medications, being treated and/or followed up in a hospital for any health disorders? -------------- □Yes □No
#3-2 Do you have any of the following symptoms? ------------------------------------------------------------------------------------- □Yes □No
□ Fatigue, Languidness □ Moderate to severe weight loss □ Sleep disturbance □ Morning depression
□ Appetite loss □ Stomach ache, Heart burn □ Nausea □ Dizziness
□ Headache □ Diarrhea □ Constipation □ Back pain/ache
□ Shortness of breath □ Persistent cough, sputum □ Chest pain/discomfort □ Joint pain/ache
□ Hearing disorder (□Lt. / □Rt.) □ Ringing in ears (□Lt. / □Rt.) □ Abdominal discomfort □ Irregular menstruation
□ Eyestrain, eye trouble □ Stiff shoulder □ Numbness of hands □ Other: ____________________
Please explain details of all “Yes” answers to the
above #3-1&2 questions (Use extra paper if needed) ： _______________________________________________________________
#3-3 Do you smoke cigarettes, cigars or a pipe? □Yes : If yes, how many per day? _____ __ For how many years? _______ □No
#3-4 Do you drink alcohol? □Yes : If yes, how often per week? _______ How many? ______ ml of (beer / whisky / wine) □No
I hereby certify that I have answered the above questions to the best
of my knowledge and that the answers are complete and true : ________________ _________________________________
Date Signature
--------------------------------------------------------------------<Comments by Occupational Health >----------------------------------------------------------------------------
□ with legal health exam. data | Assessment: □ Fit □ Fit with restrictions (need Dr’s Sig.)
□ with other med. exam. data | □ Need OH medical follow up and/or check
□ with no med. exam. data | □ More information required before determination
|
________________________ | Date _____________________ Name & Signature _______________________________

Dr’s Comments (if needed):