Agricultural Worker Health Assessment Form
Please complete this form to help us assess your health and workplace well-being as an agricultural worker.
Personal Information
Please provide your basic details.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Male
Female
Non-binary
Prefer not to say
Other
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Work Information
Details about your work in agriculture.
What is your primary job or role?
*
How many years have you worked in agriculture?
*
Have you been exposed to any of the following in your work? (Select all that apply)
*
Pesticides
Fertilizers
Heavy machinery
Loud noise
Extreme temperatures
None of the above
Other
Current Health Symptoms
Please indicate if you are currently experiencing any of the following.
Please rate the severity of the following symptoms experienced in the last two weeks:
*
Rows
None
Mild
Moderate
Severe
Cough
1
2
3
4
Shortness of breath
5
6
7
8
Skin irritation
9
10
11
12
Muscle pain
13
14
15
16
Headache
17
18
19
20
Nausea
21
22
23
24
Do you have any chronic health conditions?
*
Yes
No
If yes, please specify your chronic conditions, medications, or allergies.
General Health Rating (1 = Poor, 5 = Excellent)
*
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
Submit Assessment
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