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Medical Questionnaire for Individuals Who Drive Powered Industrial Vehicles Mobile App

Detailed Medical Questionnaire from GoCanvas for those who drive powered industrial vehicles such as trucks, tractors, cranes and more. Includes personal information and an extensive section on alcohol use. Also includes basic questions that may affect the driver's ability such as vision or hearing issues as well as several medical conditions.

  • Lendlease
  • The Cooperative
  • PG&E
  • Red Bull
  • Mirvac

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Take a peek inside the Medical Questionnaire for Individuals Who Drive Powered Industrial Vehicles Mobile App

Included Features

Our App Builder gives you the power to easily add and remove the ones you want. {{controller.show_all ? 'See included features.' : 'See more features.'}}

  • {{data.title}}

Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico date

    Date

  • Ico textbox

    Name

  • Ico textbox

    Address

  • Ico textbox

    City

  • Ico dropdown

    State

  • Ico textbox

    Zip

  • Ico textbox

    Home Phone

  • Ico textbox

    Department

  • Ico textbox

    Department Phone

  • Ico textbox

    Job Title

  • Ico textbox

    Supervisor

  • Ico textbox

    Date of Birth

  • Ico textbox

    Height

  • Ico textbox

    Weight

  • Ico textbox

    Regular Working Hours

  • Ico dropdown

    Gender

  • Ico dropdown

    Are you supposed to wear corrective lenses when you drive a car?

  • Ico dropdown

    Do you have any other vision problems?

  • Ico textbox

    If yes, describe

  • Ico dropdown

    Have you ever had your hearing checked?

  • Ico dropdown

    If yes, what were the results?

  • Ico dropdown

    Have you been advised to wear a hearing aid?

  • Ico dropdown

    If yes, do you wear it?

  • Ico statictext

    Do you currently have any of the following medical conditions?

  • Ico dropdown

    Heart Disease?

  • Ico textbox

    If yes, indicate type:

  • Ico dropdown

    High blood pressure?

  • Ico dropdown

    Diabetes?

  • ...and More!

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