THIS FORM IS TO BE COMPLETED BY CANDIDATE.
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- Avis Fitzgerald
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1 THIS FORM IS TO BE COMPLETED BY CANDIDATE. Information requested on this Candidate Pre-Placement Health Questionnaire ( Questionnaire ) is collected pursuant to Saudi Arabian Oil Company ( Saudi Aramco ) corporate guidelines. The purpose of this Questionnaire is for you to provide your health and work history so Saudi Aramco can determine: (1) Whether you are medically able to perform the job for which you have applied. It is not intended to exclude any otherwise qualified individual from obtaining employment. (2) Whether any health issues or disabilities may affect your residency in Saudi Arabia. If you need extra space to provide any additional information, use a separate sheet of paper. Please include your name, indicate the question number to which your answer refers, and sign/date each sheet. I. PERSONAL INFORMATION Country Passport Issued By Job Title Name (last name, middle name, first name) Badge No New Hire Rehire of Birth (M/D/Y) Gender Marital Status Weight (kg) Height (cm) Male Female Single Married Address Address & Telephone No II. PERSONAL MEDICAL HISTORY 1. ACTIVE CONDITIONS Have you ever had, or do you currently have any of the following active conditions? Condition Yes No Condition Yes No Allergies (e.g. latex, medicines, environmental/seasonal, foods) Gastroenterology problems (e.g. Crohn s disease, colitis) Arthritis Hearing impairment Asthma / obstructive sleep apnea Heart/vascular or circulatory problem Autoimmune/connective tissue disease High blood pressure (e.g. SLE) Back pain, injury, or disk disease Infectious disease (e.g. HIV, Hepatitis B/C, syphilis) Blood disorders (e.g. sickle cell, Kidney function impairment thalassemia) Cancer or tumors Mobility (e.g. walking, running, using stairs) Chest pain Mental or emotional illness (e.g. anxiety, depression, nervous breakdown, personality) Chronic obstructive pulmonary disease Multiple sclerosis (MS) (COPD) Chronic productive cough (e.g. pertussis) Shortness of breath Diabetes Skin problems (e.g. psoriasis, eczema) Dizziness/vertigo or frequent severe Sleep Disorder (e.g. sleep apnea) headaches / migraines Drug or alcohol or narcotic dependency Stroke/transient ischemic attack Eating disorder (e.g. bulimia, anorexia, etc) Tuberculosis 1 P age
2 Condition Yes No Condition Yes No Epilepsy/seizure disorder Ulcers, digestive or stomach problems Fractures (specify body parts) Vision impairment (e.g. visual impairment, color blindness, tunnel vision) 2. TREATMENT AND MEDICATION a. Have you ever been admitted to a specialty medical facility or hospital? Treatment Diagnosis/Condition/Outcome Yes No b. Have you ever had been advised to undergo a medical operation within the last five years? Type of Surgery Diagnosis/Condition Outcome c. Have you ever been disqualified for duty in, or discharged from the Armed Services for medical reasons? Reason for disqualification or discharge d. Do you presently have any impairment or disability or health condition not mentioned above? of onset Impairment/Disability/Health Condition Treatment e. Are you taking any prescribed medication? Medication Dosage Reason f. Do you drink alcoholic beverages? (include average number of drinks per day) g. Do you smoke? (include average number of cigarettes per day and the number of years of smoking) h. Have you ever been assessed or treated by any medical mental specialists within the last 5 years? Treated by Treatment Diagnosis/Condition/Duration of Treatment i. Have you ever been refused insurance because of a medical condition? Medical Condition 2 P age
3 3. OCCUPATIONAL INJURY OR ILLNESS a. Have you ever filed a compensation claim or received benefits as a result of an occupational injury or disease? Nature of injury or disease Yes No b. Have you lost time from work for more than five days due to illness or occupational injury in the past two years? Nature of injury or illness Duration of time lost c. Have you ever been placed on work restriction due to occupational injury or illness? Nature of injury or illness Restriction and duration 4. MEDICAL REPORTS For any positive response indicated in this Section II, please provide a corresponding report as indicated below. Each report must be dated within 90 days of this submission and include information such as onset, etiology, treatment, prognosis, diagnosis, any admissions, and current status. Condition Report A. Arthritis Rheumatology B. Asthma / COPD Pulmonology report with Pulmonary Function Test C. Back problem or any fractures Neurosurgery and/ or orthopedic D. Blood disorder Hematology E. Cancer Oncology F. Diabetes Endocrinology report with hemoglobin A1C & fasting blood sugar G. Epilepsy/Seizures Neurology report H. Frequent or severe headaches/dizziness Neurology /ENT report I. Gastroenterology problems G.I report J. Hearing impairment Audiogram and if any major problems or surgery provide ENT report K. Heart/vascular or circulatory problems Cardiology report and appropriate investigations, e.g. ECHO, stress test, EKG L. Infectious diseases Lab findings and detailed infectious disease report M. Mental or emotional illness Psychiatric /psychologist report (depends) N. Multiple sclerosis (MS) Neurology O. Sleep disorder (e.g. sleep apnea) Pulmonology report with sleep study P. Stroke Neurology Q. Vision (uncorrectable by spectacles) Ophthalmology 3 P age
4 III WORK HISTORY Please list your previous jobs, starting with the most recent. IV. PROFESSIONAL LICENSE OR CERTIFICATE If you are professionally licensed or certified to perform your current job (pilot, ship crew, respirator user, crane operator, fire fighter and others) please attach a copy of your professional license or certificate. V. AFFIRMATION AND RELEASE AUTHORIZATION I, the undersigned, hereby affirm that I have given true and complete information to the best of my knowledge regarding my medical history. I understand and accept that if, after having been employed, any false statement or misrepresentation or omitted material information will constitute a valid reason for my immediate employment termination by Saudi Aramco without termination benefits. I, the undersigned, hereby authorize the release of (1) the information I have provided herein, and (2) the results of any required medical examination, including the opinions and evaluations of the examining physicians, to Saudi Aramco and to Johns Hopkins Aramco Healthcare (JHAH) and their employees and authorized agents. I, the undersigned, do voluntarily agree to release and hold Saudi Aramco, JHAH and their employees and authorized agents harmless from any claim, demand, or cause of action for damages arising from the review and release of my medical information for the purpose of consideration for employment. Signature of Candidate 4 P age
5 Saudi Aramco Employment Candidate Medical Information Confidentiality Waiver Form I, the undersigned, hereby authorize the release of my medical information to Saudi Aramco and the Johns Hopkins Aramco Healthcare (JHAH) for the purpose of consideration for employment. Furthermore, as a condition of being considered for employment, I understand and consent to having my medical personnel involved in my hiring decision. I, the undersigned, do voluntarily agree to release and hold Saudi Aramco, JHAH and their employees and authorized agents harmless from any claim, demand or cause of action for damages arising from the review and release of my medical information for the purpose of consideration for employment. Signature of Candidate Signature of Witness 5 P age
CHRONIC PAIN EVALUATION. Please help us understand your pain by completing this drawing:
JOSE G. VELIZ MD, INC. Diplomate of the American Board of Interventional Pain Management Diplomate of the American Board of Anesthesiology Diplomate of the American Board of Pain Medicine Fellow of Interventional
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Patient information. Today s Date. Patient s Name D.O.B. Street Address Apt. No. Home Phone # Work Phone # Social Security # DL # State
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Date: New Patient Form First Visit Date: **PATIENT INFORMATION** **PRIMARY INSURANCE** Name: Insurance Company: Street: Claim Address: Facility/Complex City/state/Zip: Group #: Town/State/Zip: Policy/
Name Date. Date of Birth Social Security #: Street Address. City State Zip. Home Phone Cell Phone Address. Employer Business Phone
Barcode Label Interviewer: Office: **PLEASE USE BLACK INK** Patient Information Please Print Name Date Date of Birth Social Security #: Street Address City State Zip Home Phone Cell Phone E-Mail Address
Application for Patient
Application for Patient First Name: M.I.: Last Name: Date: Address: City: State: Zip: SS#: - - Age: DOB: / / Male / Female Email: Home #: Cell # Work # Primary Care Physician: Do we have permission to
Patient s Name Birth Date Age. Address City State Zip. Social Security # Marital Status. Phone # Voic Message Accepted Yes No
PATIENT INFORMATION Patient s Name Birth Date Age Address City State Zip Social Security # Marital Status Authorization to Contact Patient Yes No Contact Via Email or Phone Phone # Voicemail Message Accepted
CONTENTS ALL PARTS OF THIS PACKET ARE IMPORTANT, AND IT MUST BE COMPLETED IN ITS ENTIRETY!
2017-18 Point Park University Athletics Medical Packet Enclosed you will find many of the necessary forms needed to compete in intercollegiate athletics during the 2017-18 year. Please return all completed
New Client Intake. First Name Last Name. Address. City State Zipcode Date of Birth. Home Phone Mobile Phone. Relationship to you Phone
1 New Client Intake Address City State Zipcode Date of Birth Home Phone Mobile Phone Emergency Contact: Relationship to you Phone Please explain the pain you are experiencing and its origin story: https://docs.google.com/document/d/1q0tns8lwtefzbbj1n9jyt2onopvy2abs9s1ofr07zai/edit
Apt. /unit: City: State: Zip Code:
Health Profile Date: Dietary consultation involves a health profile. The purpose of the health profile is not to establish a diagnosis, but rather to determine a client s health status in order to guide
PATIENT DEMOGRAPHIC INFORMATION
PATIENT DEMOGRAPHIC INFORMATION Patient Name: (First, MI, Last) Sex: [ ] M [ ] F Birth Date: Age: SS#: Email: Race: Ethnicity: Language: Mailing Address: Work Ph: ( ) City: State: Zip Code: Home Ph: (
New Patient Form Welcome!
New Patient Form Welcome! Last First Middle Initial DOB Address City ST ZIP Phone (H) (C) Email Occupation Employer Relationship Status S M W D Spouse s Name DOB Children s Names and Ages Have you had
Thai Massage Health History Questionnaire
Name: Date: Thai Massage Health History Questionnaire Mobile Work Home Email Birthday Address Emergency Contact Name Relationship number Occupation How did you find me? When was your last massage? Where?
Student Health Services
MEDICAL RECDS of birth Home address City State ZIP Home phone number Gender identity: Pronouns: Chosen Name Class status (circle): First year Sophomore Junior Senior Graduate Postbac Premed IN CASE OF
Feil & Oppenheimer Psychological Services
Feil & Oppenheimer Psychological Services 260 Waseca Ave. Barrington, RI 02806 401-245-4040 Fax: 401-245-1240 feiloppenheimer@gmail.com Adult Patient Questionnaire Name: Today's Date: Address: Home Phone: