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The Annual Health Assessment form must be completed annually. Failure to do so by your anniversary date could result in a caregiver having to get a completely new physical exam or being put on “hold” and not being able to work on cases. We appreciate it if you could promptly fill in the form each year. Thank you.

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Health

Are You Under the Care of a Physician
Has there been any changes with your health since your last doctor visit?
Are you taking any medications?

Habituation/Addiction

I certify that I am free from a health impairment which is of potential risk to the patient or which might interfere with the performance of my duties, including the habituation or addiction to depressants, stimulants, narcotics, alcohol or other drugs or substances which may alter my behavior.
Do you have an addiction to any of the following?
1. Depressants
2. Stimulants
3. Narcotics
4. Alcohol
5. Any other drugs that may alter your behavior?
I hereby give my permission to release the results of any test and/or information regarding my health status to Sara Companion HomeCare Services Inc. I understand that I must complete an Annual Health Assessment and Annual Tuberculosis Screening Questionnaire in order to retain active employment with Sara Companion HomeCare Services Inc.
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