PATHWEL Center of Hematology
& Bone Marrow Transplant
A project of Pakistan Thalassaemia Welfare Society
Appendix-E
Health Questionnaire Form
To be filled by the employee. Please answer each question Yes or No; if "Yes", give full detail below.
Employee Name:Unaba SheikhDesignation:________________
| Have you ever been advised by a physician to have treatment / surgery / investigation for: | Answer |
|---|---|
| a) Heart disease | No |
| b) High blood pressure | No |
| c) Diabetes | No |
| d) Kidney disease | No |
| e) Cancer or brain tumor | No |
| f) Back pain / muscular problem | No |
| g) Digestive problems | No |
| h) Liver disease incl. Hepatitis B | No |
| i) AIDS | No |
| Any health problem due to smoking | No |
| Currently taking treatment / medication / awaiting investigation | No |
| Absent from work due to medical reasons (1+ week) in last 2 years | No |
| Other (please specify) | — |
Details of any "Yes" answer above
| Type of disease | Date (from) | Date (to) | Treatment from (name & address of doctor) |
|---|---|---|---|
| No conditions declared. | |||
I hereby declare that what has been stated above is true and complete to the best of my knowledge. In case of wrong information, I could be terminated from employment.
Employee Signature
Date