i-Paramedical Order Form

(Online Pre-employment Assessment)

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CONFIDENTIAL PARAMEDICAL QUESTIONNAIRE

PERSONAL AND DEMOGRAPHIC INFORMATION

File :

Date :

First and last name

Age :

Gender :

Home Address :

Home Phone :

Cell Phone :

Application for which Position :

Company’s Name :

I hereby agree to undergo a pre-hiring paramedical evaluation of which content I was informed about. I consent to give to the best of my knowledge exact information on my health status and health history. It is understood that this information will be part of my medical file and that they will stay confidential. I authorize the physician or the nurse to inform my employer regarding my capacity to execute the work as well as asking to get access to medical files, if necessary.

EMPLOYER

Company :

Petitioner :

Phone :

FAX :

E-mail :

1. Family Medical History (parents, grand-parents, brothers, sisters)

2. Personal Medical History

For each check, please specify:

3- Please answer by yes or no

Have you ever undergone a surgery?

Yes No

If so, which one?

When?

Have you ever used marijuana, heroin, L.S.D. or other drugs recently?

Yes No

Were there any specific risks at your previous jobs?

Yes No

If yes, which ones

Have you ever received work compensation due to a work accident or a health issue related to work?

Yes No

If so, describe the wound and the length of time

Have you ever received salary insurance for a long period (1 month) following a sickness or a car accident?

Yes No

If so, please explain

Due to a personal condition and/or a traffic accident and/or a work accident, do you have permanent limitations?

Yes No

If so, which ones?

Was your driver’s license ever suspended for medical reasons?

Yes No

If yes, explain

4- SLEEP

Do you usually sleep well?

Yes No

Do you sometimes have difficulty going to sleep?

Yes No

Do you often wake up during the night or early in the morning without being able to go back to sleep?

Yes No

So you feel rested on waking?

Yes No

So you suffer from disturbed sleep?

Yes No

Do you take sleeping pills?

Yes No

On 24 hours, how many hours do you usually sleep?

5- MEDICATION

Do you take medication regularly?

Yes No

If so, please indicate the name, the dosage and the frequency:

6- TOBACO

Did you smoke in the past?

Yes No

If so, do you still smoke?

Oui Non

At what age did you quit smoking?

Date you quit smoking

How many cigarettes per day did you smoke when you quit?

How many cigarettes a day do you currently consume?

How long have you smoked (if still smoke, please indicate for how long)?

How many cigars did you smoke per day when you quit?

How many cigars do you currently smoke per day?

How long have you smoked (if still smoke, please indicate for how long)?

How many pipes did you smoke per day when you quit?

How many pipes per day do you currently consume?

How long have you smoked (if still smoke, please indicate for how long)?

7- Medical File – Present health condition - Please answer yes or no

1. Do you feel hectic?

Yes No

2. Do you have 2 alcoholic beverages per day or more?

Yes No

3. Do you exercise regularly?

Yes No

4. Have you taken any medication during the last year?

Yes No

5. Do you have known allergies?

Yes No

If so, which ones?

6. Did you see a doctor during the last 12 months?

Yes No

If yes, which one and what was the reason

Do you have joints or muscular pains or stiffness?

Yes No

8. Are you aching in the neck, the back, at your shoulders or your lower back?

Yes No

9. Do you have any handicap?

Yes No

10. Do you have numbness or lost of sensitivity in a limb?

Yes No

11. Do you sometimes have swollen joints?

Yes No

12. Do you have skin problems (irritated skin)?

Yes No

13. Do you have burning and itching without evident reasons?

Yes No

14. Do you easily bruise or have redness on the skin?

Yes No

15. So you sometimes lose consciousness?

Yes No

16. Do you have significant memory lost?

Yes No

17. Do you suffer from migraines or frequent headaches?

Yes No

18. Have you ever seen a psychiatrist or a psychologist?

Yes No

19. Do you have tremors?

Yes No

20. Do you drink more than 6 coffee or tea cups per day?

Yes No

21. Do you have frequent heartburns?

Yes No

22. Do you have digestion problems?

Yes No

23. So you often have diarrhea?

Yes No

24. Do you frequently have abdominal pains without evident reasons?

Yes No

25. Did you ever vomit blood?

Yes No

26. Have you ever found blood in your stools?

Yes No

27. Did you lost weight recently without any evident reasons?

Yes No

28. Is it burning when you urinate?

Yes No

29. Do you have difficulties to urinate?

Yes No

30. Did you ever found blood in your urine?

Yes No

31. Do you wear glasses or contact lens?

Yes No

32. Do you have sometimes blurry vision?

Yes No

33. Do you feel your eyes tearing and blinking without any reason?

Yes No

34. Do you have double vision at times?

Yes No

35. Do you see colored halos around lights?

Yes No

36. Do you see black dots at times?

Yes No

37. Did you have an earache recently?

Yes No

38. Does it happen that your ears run?

Yes No

39. Have you noticed if you had difficulty hearing recently?

Yes No

40. Are your ears buzzing at times?

Yes No

41. Do you have dizzy spell?

Yes No

42. Do you get travel-sick (nausea, seasickness, etc.)?

Yes No

43. Is your nose blocked without having a cold?

Yes No

44. Is your nose running without having a cold?

Yes No

45. Do you have sneezing crisis?

Yes No

46. Are you congested for long periods of time?

Yes No

47. Do you nose bleed without reason?

Yes No

48. Have you got sore throat without having a cold?

Yes No

49. Is your voice hoarsely without having a cold?

Yes No

50. Do you get short of breath?

Yes No

51. Do you get coughing fit frequently?

Yes No

52. Have you ever spit blood?

Yes No

53. Have you had a pulmonary X-Ray during the last 12 months?

Yes No

54. Were you ever told that your blood pressure was high?

Yes No

55. Do you have pain or pangs in the chest?

Yes No

56. Do you get palpitations without reasons?

Yes No

57. Do you feel your ankles and your feet swollen often?

Yes No

58. Do you take medication for the hearth, blood circulation or blood pressure?

Yes No

59. Do you have cramps in your legs when walking or during the night?

Yes No

60. Did you ever have an electrocardiogram?

Yes No

61. Are you out of breath after a minimal effort?

Yes No

62.(MEN ONLY) Have you got a prostate problem confirmed by a physician?

Yes No

63.(MEN ONLY) Do you have bumps or swelling testicles?

Yes No

64.(MEN ONLY) Do you have discharge at the penis, burning and/or itching sensation?

Yes No

65. (WOMEN ONLY) Do you have difficult and painful menstrual periods?

Yes No

66. (WOMEN ONLY) Do you have abundant menstrual fluid?

Yes No

67. (WOMEN ONLY) Have you ever had bumps on the breast?

Yes No

68. (WOMEN ONLY) Do you have abundant vaginal discharge, vaginal burning sensations?

Yes No

69. (WOMEN ONLY) Have you ever had a miscarriage?

Yes No

8- STRESS

Inventory of your stress symptoms

This part of the questionnaire has for goal to raise your awareness of all the signs, physical as well as psychological, associated with stress. Those signs or symptoms are good indicators to see how tense you actually are. This questionnaire is based on the one elaborated by Jacques Lafleur, psychologist, and Robert Béliveau, physician.

For the following questions, check how you felt for each symptom during the last month:

0 you did not feel this way at all.
1 you did slightly feel this way or felt it rarely.
2 you felt it moderately or quite often.
3 you feel this way often or constantly.

Note: The statements with an asterisk indicate a beneficial stress state, which we call balance. You must answer those statements in the same way you do for the other symptoms.

Physical Symptoms

Muscular Tension Symptoms

My muscles are rather relaxed

I feel tense in the face (tight jaws, forehead wrinkled, etc.).

I feel tension at the nape of the neck or at the neck.

I feel pressure on my shoulders.

I feel tense (tight fists, tendency to get startled, etc.).

I feel a knot between the shoulder blades.

I have tension headaches (due to muscular tension).

I have backaches.

I have tremors.

I can’t stand still.

I have difficulty to relax.

Other physical symptoms

am healthy.

I feel tired.

I have butterflies in the stomach.

I feel a lump in my throat.

I have shadow under my eyes.

I don’t sleep well or I take medication to sleep.

I don’t eat (or less) as usual.

I have hot flashes or shivers.

I have palpitations.

I often have cold hands or cold feet.

I perspire, I have sweaty hands.

I am out of breath or difficulty to take a deep breath.

I have digestion problems.

I have heart burns.

I am constipated or have diarrhea.

I feel nauseous.

My menstrual cycle has change.

Psychological Symptoms

Symptoms related to emotions

I feel joyful.

I worry for nothing and everything.

I do panic.

I lack patience.

I am always on edge.

I feel frustrated.

I change moods in twitch.

I lose my temper over the slightest thing.

I am in a bad mood.

I feel sad.

I feel depressed.

Symptoms related to perception of things

I find life pleasurable.

I lost my sense of humor.

I feel overloaded and pressed.

I do not enjoy the small things in life.

I am worried.

Everything seems high as a mountain.

As soon as I see someone, I worry they might want to ask me something.

I lost my self-confidence.

I tend to see a disaster over nothing.

I have a negative attitude, I take everything the wrong way.

I feel like I’m not worth much or that everything I do is useless.

Symptoms related to motivation

I feel motivated by my projects.

My tasks come first.

I don’t know what I want.

I lack enthusiasm.

I don’t feel like doing anything.

I have difficulties to get going, I tend to postpone to the next day.

I lost my desire for learning and self growth.

I feel dishearten.

Symptoms related to behaviour

I usually act in a safe and proper manner.

I have abrupt manners, I drop everything, I am clumsy.

I do everything rapidly (eat, walk, move, work, etc.).

I stump, snap my fingers, I bite my inside cheek.

I bite my nails, have nervous laughs, etc.

I always wonder what time it is.

I skip meals.

I do more and more efforts for less and less results.

I avoid everything I can avoid.

I drink more coffee or more alcohol.

I smoke more.

I take medication for my nerves.

I take drugs.

Symptoms related to intellectual functions

I feel in full control of all my intellectual powers.

I spend lots of time for entertainment (TV, gossips, easy games, etc.).

I have a swirl of ideas in mind.

My ideas are confused.

I have fixed ideas.

I brood over the same things, I go round and round, without finding an answer.

I have difficulty concentrating.

I have some memory problems.

I never produce anything from an intellectual point of view.

I find that everything is always too complicated.

My mind is completely empty.

Symptoms related to my social life

I’m comfortable with others and I feel good when I am alone.

I am afraid to meet new people.

I am intolerant.

I have a lot of resentment.

I constantly show aggressive behaviour.

I have difficulty to be amicable.

I don’t feel like listening to others.

I shun intimate relations.

I get distracted when I am in the presence of other people.

I isolate myself.

Symptoms related to life

I think life is beautiful.

I feel useless.

I don’t know which values I should hold to.

My spiritual life has changed.

I feel like something in me is broken.

I feel like I don’t recognize myself.

I have reached the end of my rope.

I feel a big emptiness inside me.

I think life does not make sense.

I am in despair.

I have suicidal ideas.

I certify that the information above is accurate and that a false statement could be a cause for dismissal.