Form updated 6/30/22

Please fill in all information completely and press the submit button when you are finished. Thank you.

If you have any questions, please contact Sara Companion HomeCare Services and speak with a member of our Human Resources Team.

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Name *

Date *

Position *

Health

Are You Under the Care of a Physician *

• Yes
• No

If you answered yes, please explain:

What is the last date that you saw your doctor? *

Has there been any changes with your health since your last doctor visit? *

• Yes
• No

If you answered yes, please explain:

Are you taking any medications? *

• Yes
• No

If you answered yes, please list the medications that you are taking:

Habituation/Addiction

I certify that I am free from a health impairment which is of potential risk to the patient or which might interfere with the performance of my duties, including the habituation or addiction to depressants, stimulants, narcotics, alcohol or other drugs or substances which may alter my behavior. *

• Yes
• No

Do you have an addiction to any of the following? *

• Yes
• No

1. Depressants *

• Yes
• No

2. Stimulants *

• Yes
• No

3. Narcotics *

• Yes
• No

4. Alcohol *

• Yes
• No

5. Any other drugs that may alter your behavior? *

• Yes
• No

I hereby give my permission to release the results of any test and/or information regarding my health status to Sara Companion HomeCare Services Inc. I understand that I must complete an Annual Health Assessment and Annual Tuberculosis Screening Questionnaire in order to retain active employment with Sara Companion HomeCare Services Inc. *

• Yes
• No

Employee Signature *

Clear Signature

Date *

Submit