Employee Health Record

Employee Name:

Address:

Phone:

Date Employed:

Position:

In Emergency please notify:

Relationship:

Address:

Phone:

Sex [ ] Male [ ] Female [ ] Age [ ] Exam

Date of Pre-Employment:

Local Physician:

Address:

Phone:

Medical History (Allergies, Restrictions, Etc:

Date: Time: _______ Am/Pm

lness/Injury:

Treatment/Action:

Contract law requirements

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