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Health Questionnaire and Liability Consent 

In an effort to ensure the wellbeing of their employees, your hiring company has been contracted Active Energy LLC to instituted Post-Offer, Pre-Placement Testing (PPT) for all new hires.

 

The applicant must complete a medical history and must partake in a pre-test physical screening. The PPT portion of this process will reflect the physical demands of the job and may require lifting, pulling, pushing, gripping, climbing, and repetitive tasks. If the evaluator finds reason to stop testing based upon medical findings the offer of employment will be withdrawn. The applicant then has 30 days to obtain a release from [his/her] physician stating that it is safe to proceed testing. Should the evaluation process reveal medical information indicating that the applicant may be at risk to [himself/herself] or co-workers that information will be reported to the hiring company. This information will not be used to deny employment, but will be maintained in the employee’s medical file, which will remain separate from their employment file, to ensure the employee’s safety in the future.

 

Your employer has taken every step to ensure compliance with the Americans with Disabilities Act and our own stringent standard of equal opportunity employment. As such, the company has engaged the services of an outside firm specializing in industrial injury prevention to administer the PPT. Active Energy LLC, will forward a letter indicating that you have met or not met the safety and physical demands reflected in the test to your hiring entity and pertinent findings from that test; as noted above, all other information gathered during the screening and testing process will be retained in the files of the Active Energy LLC.

 

Your employer will not use the results of this test to discriminate against anyone on the basis of disability, gender, age, race, religion, veteran status, marital status or sexual orientation. All job offers will be contingent on the applicant meeting the requirements of the PPT. Anyone who is denied employment will be denied as a result of not meeting those requirements that are job-related and consistent with business necessity.

 

BENEFITS OF TESTING: Ensure applicant’s ability to safely perform the essential functions of the job which [he/she] is applying.

 

RISKS OF TESTING: The test requires the applicant exert effort to perform the critical physical demands of the job for which [he/she] is applying. Those demands may include repetitive lifting to [his/her] maximum safe level, working in awkward postures, performing whole-body movements that may stress the cardiorespiratory system and other physical demands as required. The applicant must understand that there is a risk of injury while participating in this type of testing and assumes all responsibility. 

 

SAFETY SCREENING; Prior to beginning the physical screening and testing portion of this process, the applicant will be asked to complete an up-to-date medical history. To ensure safety during testing it is essential that the applicant complete the medical history completely and accurately. Failing to do so may jeopardize the applicant’s safety and employability.

 

I have read and understand the above policy regarding PPT. I understand the benefits, risks, and responsibilities of participating the PPT. I understand that I have been offered a job knowing my employment is contingent upon successful completion of the PPT.

 

I also understand the hiring entity will pay the fee for the test. I agree to provide the staff of the Active Energy LLC with my complete medical history and participate at a safe level in testing in order to ensure my safety. I accept the risk involved in this type of test, I take full responsibility of myself and any resulting injury and wish to participate.

 


 

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Date of last physical by physician?

Purpose of physical?
Check all that apply. *
Allergies
Anemia
Chest Pain
Arthritis/Gout
Asthma
Cancer
Chronic Bronchitis
Diabetes
Emphysema
Heart Disease
Hepatitis/Jaundice
High Blood Pressure
Hypoglycemia
Migraine Headaches
Muscle/Bone Injuries
Nerve Injuries
Pneumonia
Rheumatic Fever
Seizures
Shortness of Breath
Stroke
Ulcers/Stomach Problems
Vision Problems
Other
None

Explain any issues selected above.
Musculoskeletal Conditions: check any that may apply. *
Spine, neck or back injury/pain.
Thoracic Outlet Syndrome
Carpal Tunnel Syndrome
Upper Extremity Injury/Pain
Lower Extremity Injury/Pain
Other
None

Explain any issues selected above.

List any surgeries in the last two years.

List any medications you are currently taking.

List any X-ray, CT scan, or MRI in the last year and what it was for.
Are you pregnant?*
No
Yes
Are you taking any medications or substances that are illegal in this state?*
No
Yes

List any other medical information we should know prior to testing for your safety.
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Date of last physical by physician?

Purpose of physical?
Check all that apply. *
Allergies
Anemia
Chest Pain
Arthritis/Gout
Asthma
Cancer
Chronic Bronchitis
Diabetes
Emphysema
Heart Disease
Hepatitis/Jaundice
High Blood Pressure
Hypoglycemia
Migraine Headaches
Muscle/Bone Injuries
Nerve Injuries
Pneumonia
Rheumatic Fever
Seizures
Shortness of Breath
Stroke
Ulcers/Stomach Problems
Vision Problems
Other
None

Explain any issues selected above.
Musculoskeletal Conditions: check any that may apply. *
Spine, neck or back injury/pain.
Thoracic Outlet Syndrome
Carpal Tunnel Syndrome
Upper Extremity Injury/Pain
Lower Extremity Injury/Pain
Other
None

Explain any issues selected above.

List any surgeries in the last two years.

List any medications you are currently taking.

List any X-ray, CT scan, or MRI in the last year and what it was for.
Are you pregnant?*
No
Yes
Are you taking any medications or substances that are illegal in this state?*
No
Yes

List any other medical information we should know prior to testing for your safety.
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Date of last physical by physician?

Purpose of physical?
Check all that apply. *
Allergies
Anemia
Chest Pain
Arthritis/Gout
Asthma
Cancer
Chronic Bronchitis
Diabetes
Emphysema
Heart Disease
Hepatitis/Jaundice
High Blood Pressure
Hypoglycemia
Migraine Headaches
Muscle/Bone Injuries
Nerve Injuries
Pneumonia
Rheumatic Fever
Seizures
Shortness of Breath
Stroke
Ulcers/Stomach Problems
Vision Problems
Other
None

Explain any issues selected above.
Musculoskeletal Conditions: check any that may apply. *
Spine, neck or back injury/pain.
Thoracic Outlet Syndrome
Carpal Tunnel Syndrome
Upper Extremity Injury/Pain
Lower Extremity Injury/Pain
Other
None

Explain any issues selected above.

List any surgeries in the last two years.

List any medications you are currently taking.

List any X-ray, CT scan, or MRI in the last year and what it was for.
Are you pregnant?*
No
Yes
Are you taking any medications or substances that are illegal in this state?*
No
Yes

List any other medical information we should know prior to testing for your safety.
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Date of last physical by physician?

Purpose of physical?
Check all that apply. *
Allergies
Anemia
Chest Pain
Arthritis/Gout
Asthma
Cancer
Chronic Bronchitis
Diabetes
Emphysema
Heart Disease
Hepatitis/Jaundice
High Blood Pressure
Hypoglycemia
Migraine Headaches
Muscle/Bone Injuries
Nerve Injuries
Pneumonia
Rheumatic Fever
Seizures
Shortness of Breath
Stroke
Ulcers/Stomach Problems
Vision Problems
Other
None

Explain any issues selected above.
Musculoskeletal Conditions: check any that may apply. *
Spine, neck or back injury/pain.
Thoracic Outlet Syndrome
Carpal Tunnel Syndrome
Upper Extremity Injury/Pain
Lower Extremity Injury/Pain
Other
None

Explain any issues selected above.

List any surgeries in the last two years.

List any medications you are currently taking.

List any X-ray, CT scan, or MRI in the last year and what it was for.
Are you pregnant?*
No
Yes
Are you taking any medications or substances that are illegal in this state?*
No
Yes

List any other medical information we should know prior to testing for your safety.
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Date of last physical by physician?

Purpose of physical?
Check all that apply. *
Allergies
Anemia
Chest Pain
Arthritis/Gout
Asthma
Cancer
Chronic Bronchitis
Diabetes
Emphysema
Heart Disease
Hepatitis/Jaundice
High Blood Pressure
Hypoglycemia
Migraine Headaches
Muscle/Bone Injuries
Nerve Injuries
Pneumonia
Rheumatic Fever
Seizures
Shortness of Breath
Stroke
Ulcers/Stomach Problems
Vision Problems
Other
None

Explain any issues selected above.
Musculoskeletal Conditions: check any that may apply. *
Spine, neck or back injury/pain.
Thoracic Outlet Syndrome
Carpal Tunnel Syndrome
Upper Extremity Injury/Pain
Lower Extremity Injury/Pain
Other
None

Explain any issues selected above.

List any surgeries in the last two years.

List any medications you are currently taking.

List any X-ray, CT scan, or MRI in the last year and what it was for.
Are you pregnant?*
No
Yes
Are you taking any medications or substances that are illegal in this state?*
No
Yes

List any other medical information we should know prior to testing for your safety.
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Date of last physical by physician?

Purpose of physical?
Check all that apply. *
Allergies
Anemia
Chest Pain
Arthritis/Gout
Asthma
Cancer
Chronic Bronchitis
Diabetes
Emphysema
Heart Disease
Hepatitis/Jaundice
High Blood Pressure
Hypoglycemia
Migraine Headaches
Muscle/Bone Injuries
Nerve Injuries
Pneumonia
Rheumatic Fever
Seizures
Shortness of Breath
Stroke
Ulcers/Stomach Problems
Vision Problems
Other
None

Explain any issues selected above.
Musculoskeletal Conditions: check any that may apply. *
Spine, neck or back injury/pain.
Thoracic Outlet Syndrome
Carpal Tunnel Syndrome
Upper Extremity Injury/Pain
Lower Extremity Injury/Pain
Other
None

Explain any issues selected above.

List any surgeries in the last two years.

List any medications you are currently taking.

List any X-ray, CT scan, or MRI in the last year and what it was for.
Are you pregnant?*
No
Yes
Are you taking any medications or substances that are illegal in this state?*
No
Yes

List any other medical information we should know prior to testing for your safety.
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Date of last physical by physician?

Purpose of physical?
Check all that apply. *
Allergies
Anemia
Chest Pain
Arthritis/Gout
Asthma
Cancer
Chronic Bronchitis
Diabetes
Emphysema
Heart Disease
Hepatitis/Jaundice
High Blood Pressure
Hypoglycemia
Migraine Headaches
Muscle/Bone Injuries
Nerve Injuries
Pneumonia
Rheumatic Fever
Seizures
Shortness of Breath
Stroke
Ulcers/Stomach Problems
Vision Problems
Other
None

Explain any issues selected above.
Musculoskeletal Conditions: check any that may apply. *
Spine, neck or back injury/pain.
Thoracic Outlet Syndrome
Carpal Tunnel Syndrome
Upper Extremity Injury/Pain
Lower Extremity Injury/Pain
Other
None

Explain any issues selected above.

List any surgeries in the last two years.

List any medications you are currently taking.

List any X-ray, CT scan, or MRI in the last year and what it was for.
Are you pregnant?*
No
Yes
Are you taking any medications or substances that are illegal in this state?*
No
Yes

List any other medical information we should know prior to testing for your safety.
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Date of last physical by physician?

Purpose of physical?
Check all that apply. *
Allergies
Anemia
Chest Pain
Arthritis/Gout
Asthma
Cancer
Chronic Bronchitis
Diabetes
Emphysema
Heart Disease
Hepatitis/Jaundice
High Blood Pressure
Hypoglycemia
Migraine Headaches
Muscle/Bone Injuries
Nerve Injuries
Pneumonia
Rheumatic Fever
Seizures
Shortness of Breath
Stroke
Ulcers/Stomach Problems
Vision Problems
Other
None

Explain any issues selected above.
Musculoskeletal Conditions: check any that may apply. *
Spine, neck or back injury/pain.
Thoracic Outlet Syndrome
Carpal Tunnel Syndrome
Upper Extremity Injury/Pain
Lower Extremity Injury/Pain
Other
None

Explain any issues selected above.

List any surgeries in the last two years.

List any medications you are currently taking.

List any X-ray, CT scan, or MRI in the last year and what it was for.
Are you pregnant?*
No
Yes
Are you taking any medications or substances that are illegal in this state?*
No
Yes

List any other medical information we should know prior to testing for your safety.
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Date of last physical by physician?

Purpose of physical?
Check all that apply. *
Allergies
Anemia
Chest Pain
Arthritis/Gout
Asthma
Cancer
Chronic Bronchitis
Diabetes
Emphysema
Heart Disease
Hepatitis/Jaundice
High Blood Pressure
Hypoglycemia
Migraine Headaches
Muscle/Bone Injuries
Nerve Injuries
Pneumonia
Rheumatic Fever
Seizures
Shortness of Breath
Stroke
Ulcers/Stomach Problems
Vision Problems
Other
None

Explain any issues selected above.
Musculoskeletal Conditions: check any that may apply. *
Spine, neck or back injury/pain.
Thoracic Outlet Syndrome
Carpal Tunnel Syndrome
Upper Extremity Injury/Pain
Lower Extremity Injury/Pain
Other
None

Explain any issues selected above.

List any surgeries in the last two years.

List any medications you are currently taking.

List any X-ray, CT scan, or MRI in the last year and what it was for.
Are you pregnant?*
No
Yes
Are you taking any medications or substances that are illegal in this state?*
No
Yes

List any other medical information we should know prior to testing for your safety.
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Date of last physical by physician?

Purpose of physical?
Check all that apply. *
Allergies
Anemia
Chest Pain
Arthritis/Gout
Asthma
Cancer
Chronic Bronchitis
Diabetes
Emphysema
Heart Disease
Hepatitis/Jaundice
High Blood Pressure
Hypoglycemia
Migraine Headaches
Muscle/Bone Injuries
Nerve Injuries
Pneumonia
Rheumatic Fever
Seizures
Shortness of Breath
Stroke
Ulcers/Stomach Problems
Vision Problems
Other
None

Explain any issues selected above.
Musculoskeletal Conditions: check any that may apply. *
Spine, neck or back injury/pain.
Thoracic Outlet Syndrome
Carpal Tunnel Syndrome
Upper Extremity Injury/Pain
Lower Extremity Injury/Pain
Other
None

Explain any issues selected above.

List any surgeries in the last two years.

List any medications you are currently taking.

List any X-ray, CT scan, or MRI in the last year and what it was for.
Are you pregnant?*
No
Yes
Are you taking any medications or substances that are illegal in this state?*
No
Yes

List any other medical information we should know prior to testing for your safety.
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Date of last physical by physician?

Purpose of physical?
Check all that apply. *
Allergies
Anemia
Chest Pain
Arthritis/Gout
Asthma
Cancer
Chronic Bronchitis
Diabetes
Emphysema
Heart Disease
Hepatitis/Jaundice
High Blood Pressure
Hypoglycemia
Migraine Headaches
Muscle/Bone Injuries
Nerve Injuries
Pneumonia
Rheumatic Fever
Seizures
Shortness of Breath
Stroke
Ulcers/Stomach Problems
Vision Problems
Other
None

Explain any issues selected above.
Musculoskeletal Conditions: check any that may apply. *
Spine, neck or back injury/pain.
Thoracic Outlet Syndrome
Carpal Tunnel Syndrome
Upper Extremity Injury/Pain
Lower Extremity Injury/Pain
Other
None

Explain any issues selected above.

List any surgeries in the last two years.

List any medications you are currently taking.

List any X-ray, CT scan, or MRI in the last year and what it was for.
Are you pregnant?*
No
Yes
Are you taking any medications or substances that are illegal in this state?*
No
Yes

List any other medical information we should know prior to testing for your safety.
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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