Affordable Senior Care Services, Elderly Home Care Services, Child Care Services, Home Care Provided by 24/7 Live-in or Come-go European Caregivers, Companions, Certified Nurse's Aides, Nannies, Sitters, Homemakers. Service in IL, WI, IN, MI

Assisting you life at home

Home     Senior Services     Child care     Contact Us     FAQ     Employment     Diet links     Cleaning Service     Handyman Service     Site Map      
Become a CareGiver     Health form     Links      

First Time Home Care                                                  Health  Examination  Record                   Print       

3824  S.  Grand

Western Springs IL 60558

(773) 625-2068  Phone & Fax

 

Name ______________________________________________________________

DOB _____________ Address___________________________________________

Emergency Contact____________________________ Relationship _____________

              

                   Applicant; Have you had any of the following? (Please Circle)


Operations                 Yes    No                                 Epilepsy                      Yes    No

Back Injury                Yes    No                                 Rheumatism                 Yes    No

Tuberculosis               Yes    No                                 Skin Disease                Yes    No

Drug Dependency       Yes    No                                 Head Injury                 Yes    No

Chronic Back Pain      Yes    No                                 Sinus Trouble               Yes    No

Stomach Trouble         Yes    No                                 Fractures                     Yes    No

Mental Disease            Yes    No                                 Other Injuries               Yes    No

Asthma                        Yes    No                                 Heart Trouble               Yes    No

Hernia                          Yes    No                                Alcohol Dependency     Yes    No


           

I have read the above and declare that I had no injury, illness, or ailment other then as specifically stated herein. Falsification of misrepresentation will be sufficient grounds for my release from employment.

 

Applicant Signature _______________________________________________date___________

 

Ears______________________________________ normal

Eyes____________________________________________

Teeth___________________________________________

Nose and Throat __________________________________

Skin ____________________________________________

Scars____________________________________________

Hearth___________________________________________

Longs___________________________________________

Abdomen________________________________________

Hernia___________________________________   TB Test__________________________

Extremities ______________________________________

Menstrual History_________________________________  Height_____________________

Blood Pressure___________________________________   Weight ____________________

T ___________ P_____________                                            

 

I certified that __________________________________________ is mentally and physically  able to perform the duties as ______________________

Date_____________________ Examining Physician_______________________________      

 

 

 

 

 

 

 

 

 

                                                                                                                                                                                                                       1homecare.net