Driver Health Questionaire

Health Questionaire

Instructions: Please answer all questions completely regarding injuries or health problems. You can fill out and submit this questionaire on-line or you can print it and either mail or fax to:
Horseshoe Express, Inc.
P.O. Box 17836
Salt Lake City, UT 84117
Fax: (801) 292-8828

Name		Date
E-mail

Have you ever had any of the folowing problems with any of the following:

Head
Yes
No
Shoulder
Yes
No
Hand
Yes
No
Neck
Yes
No
Arm
Yes
No

Back
Yes
No
Leg
Yes
No
Knees
Yes
No
Ankles
Yes
No
Internal Injury
Yes
No

If you answered yes to any of the above questions, when where you first treated?

Physicians description of injury(s).

What treatment did you recieve?

Was the problem work related?	Yes No
If yes, did you recieve a permanent impairment rating?	Yes No	If yes, what percentage?
Did you lose time from work?	Yes No	How much time?
Did you recieve workmans compensation?	Yes No	How long did you recieve benefits?

Are you being treated for high blood pressure?	Yes No	If yes, what medication(s) do you take?
Are you being treated for Diabetes?	Yes No	If yes, what medication(s) do you take?
List any health problems you have had.
Do you have any health problems now?	Yes No	If yes, describe.
I certify that the above information is correct.