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Name *

Address *

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

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Employee Signature *

Clear Signature

Date *

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Got Questions? Please Call

Annual Health Assessment

Health

Habituation/Addiction

Contact Details

Sara Companion HomeCare Services, Inc. Valley Stream Office

Sara Companion HomeCare Services Queens Office (Cross Island Plaza Bldg.)

Sara Companion HomeCare Services Suffolk County