Pre-Employment Medical Screening Intake Form

Pre-Employment Medical Screening Intake Form — Form Fields

This healthcare template includes 11 fields. Medical intake form for new hires undergoing pre-employment health and fitness screening. Free to customize and use on ZenBuild.

• Full Legal Name (text, required)
• Email Address (email, required)
• Date of Birth (text, required)
• Position Applied For (text, required)
• Primary Care Physician (have one?) (dropdown selection, required) — options: Yes, No
• Do you currently take any prescription medications? (dropdown selection, required) — options: Yes, No
• List current medications and dosages (if yes above) (long text, optional)
• Have you had any surgeries in the last 5 years? (dropdown selection, required) — options: Yes, No
• Describe surgeries or hospitalizations if applicable (long text, optional)
• I consent to this medical screening as part of the hiring process (checkboxes, required)
• Do you have any conditions that may affect physical job performance? (dropdown selection, required) — options: Yes, No, Prefer Not to Say