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Risk Management

Confidential Report of Medical History

To Be Used for Insurance Purposes Only

Name:

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
2. Diabetes
3. Cardiac disease
4. Arthritis
5. Amputated foot, leg, arm, or hand
6. Loss of sight of one or both eyes or partial loss of more than 75% bilateral
7. Any disability resulting from polio
8. Cerebral palsy
9. Multiple sclerosis
10. Parkinson's disease
11. Stroke
12. Tuberculosis
13. Silicosis (lung disease)
14. Psychoneurotic disability
15. Hemophilia (free bleeding)
16. Chronic osteomyelitis (inflamation of the bone)
17. Hyperinsulinism
18. Muscular dystrophy
19. Hardening of the arteries
20. Thrombophlebitis (blood clots)
21. Varicose veins
22. Heavy metal poisoning
23. Ionizing radiation injury
24. Compressed air sequelae
25. Ruptured disc
26. Ankylosis of joints
27. Hodgkin's disease
28. Brain damage
29. Deafness
30. Cancer
31. Sickle cell anemia
32. Pulmonary disease (lungs)

COMMENTS:

I understand this questionnaire is for the purpose of enabling Clemson University to fulfill 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.

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