Construction Worker Health Assessment Form
Please complete this form to help us evaluate your current health status and work readiness. All questions are non-sensitive and focused on general well-being.
Full Name
*
First Name
Last Name
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How do you rate your overall physical health today?
*
1
2
3
4
5
Have you experienced any of the following symptoms in the past week?
*
Fever
Cough
Shortness of breath
Muscle aches
None of the above
Are you currently able to perform your regular work duties without limitation?
*
Yes
No
If you have any work limitations, please briefly describe them.
Have you had any recent injuries or illnesses that affected your work?
*
Yes
No
Are you currently taking any medications that may impact your work?
*
Yes
No
Do you require any workplace accommodations at this time?
*
Yes
No
Do you believe a follow-up health assessment is needed?
*
Yes
No
Not sure
Submit Assessment
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