Occupational Health Intake Form

Employee Name*

Date of Birth*

Job Title*

Department*

Purpose of Visit*

Pre-Employment Screening

Annual Health Check

Return to Work

Injury Follow-Up

Other

Current Health Conditions

Workplace Exposures

Are you currently experiencing any work-related symptoms?*

What is this form?

An occupational health intake form for workplace health programs. Captures employee health status, work environment exposures, and fitness for duty.

Occupational health nurses, workplace health programs, and employee wellness coordinators.