Physical Examination Report

For New Employees

Name: Address:_________________________________________ Birthdate :________________________ Phone Number:___________________

Past Medical History: (place an X in the appropriate box)

Do you have a History of:
Allergies Arthritis Asthma/respiratory problems Back problems Bleeding gums Cancer (growths/tumors) Concussion(s) Diabetes Drug/Alcohol abuse Fatigue Fevers/night sweats Glaucoma Hearing problems Heart Disease

Yes

No

Do you have a History of:

Heart Murmur Hypertension Indigestion Kidney problems Mental illness Migraine headache Physical disability Seizures Sinus problems Skin disorder Speech problems Strep throat Tuberculosis Visual problems

Yes

No

Serious illness/injury in past 3 years. (Specify with date):____________________________________ Past Surgical Procedures:_____________________________________________________________ Current Medications:__________________________________________________________________ REQUIRED IMMUNIZATIONS (Birth Five Program) Tuberculin Test (Mantoux) Diphtheria Tetanus (DT) Date Results Negative: t Positive: t N/A

Physical Examination:
Height Weight B.P. Pulse:______________ Visual Acuity (rt) (lt) Hearing Acuity (rt) Peripheral Vision: _______________________Color Blind?_________ Head: Ears: Nose: Throat and Neck: Cardiovascular: Skin: Urinalysis: Sugar: Respiratory: Abdomen: Genitourinary: Musculoskeletal: Metabolic/Endocrine: Extremities: Protein:

(lt)

I hereby certify that I have examined the above named applicant and find he/she is physically qualified for lawful employment: _________________________________________ _________________________ Physicians Signature Date of Examination _________________________________________ ________________________ Address Phone Number