Information about health information check list
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This information will be handled in a confidential manner. It is essential that you answer all questions truthfully and completely. False or incomplete information may result in disqualification or termination if hired. Completed by Applicant/Employee (Type or Print in Ink) Section I Date: Employee Name: Social Security Number -- Last, First Middle Employing Agency: Date Employed: Section II Have you now, or ever had the following? Yes No Yes No 1. Loss of sight of both eyes. Loss of uncorrected (without glasses or contact lens) vision of more than 75% bilaterally (vision of 20/160 or J or worse using both eyes). Yes No Yes No 1. Epilepsy (convulsions, seizures, or fits) 14. Psychoneurotic disability following confinement for treatment in a recognized medical or mental hospital for a period in excess of six months.2. Diabetes15. Hemophilia3. Tuberculosis 16. Sickle cell anemia4. Epilepsy (convulsions, seizures or fits) 17. Cardiovascular (heart or blood vessel) disease 5. Ankylosis (immobility) of major weight bearing joints (ankles, knee, hip)18. Total occupational loss of hearing (loss of over half of hearing in each ear) 6. Any permanent condition which causes 20% (or more) impairment of a foot, leg, hand, arm, back, or the body as a whole 19. Compressed air sequelae (damage to lungs, ruptured ear drum, etc due to air concussion, blasting, explosion, etc.)7. Arthritis which is a hindrance to employment 20. Muscular dystrophy9. Amputated (loss of) foot, leg, arm, or hand 21 Hyperinsulinism (hypoglycemia)10. Parkinsons disease (Paralysis Agitans)22. Residual disability from poliomyelitis (Disability due to polio)11. Cerebral palsy23. Ruptured intervertebral (back) disc12. Multiple sclerosis23. Chronic osteomyelitis (bone infection)13. Mental retardation (intelligence quotient within the lowest two percent of the general population)24. 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