Clemson University

Confidential Report of Medical History (To be completed by employee)

TO BE USED FOR INSURANCE PURPOSES ONLY

Name: SS No:
Address:

Phone:

E-mail:
Dept/ Pos. No: Dept Name:

Personal Physician:

Male: Female:

Indicate if you have ever had or now have any of the following conditions:

1.

Epilepsy

17.

 Hyperinsulinism
2. Diabetes
18.
 Muscular Dystrophy
3. Cardiac Disease
19.
 Hardening of the arteries
4. Arthritis
20.
 Thrombophlebitis (blood clots)
5. Amputated foot, leg, arm, or hand
21.
 Varicose veins
6. Loss of sight of one or both eyes or partial loss of more than 75% bilateral
22.
 Heavy metal poisoning
7. Any disability resulting from polio
23.
 Ionizing radiation injury
8. Cerebral palsy
24.
 Compressed air sequelae
9. Multiple sclerosis
25.
 Ruptured disc
10. Parkinson's disease
26.
 Ankylosis of joints
11. Stroke
27.
 Hodgkin's disease
12. Tuberculosis
28.
 Brain damage
13.

Silicosis (lung disease)
29.
 Deafness
14. Psychoneurotic disability
30.
 Cancer
15. Hemophilia (free bleeding)
31.
 Sickle-cell anemia
16. Chronic osteomyelitis (inflamation of the bone)
32.
 Pulmonary disease (Lungs)

 

 

COMMENTS:

I understand this questionnaire is for the purpose of enabling Clemson University to fulfil the requirements of the South Carolina Second Injury Fund. The information provided is not to be used by Clemson University as a basis of denying me placement within the Company or promotion, or to discriminate against me in any way. By submitting this form I attest that the information provided is true to the best of my information and belief.

 

Note: The above information is for official use only and will not be released to unauthorized persons.