Pdf Blank Physical Exam Forms Details

Employees are a company's most important resource. That is why it is so important to have up-to-date employee physical forms on file. This way, you can be sure that you are aware of any health risks your employees may have and can take steps to mitigate them. Having up-to-date physical forms also helps when it comes time to make decisions about promotions or layoffs, as you will have a complete picture of each employee's health. If your company does not currently have employee physical forms, or if they are out of date, now is the time to update them. You can find templates for these forms online, or you can work with an HR consultant to create custom forms for your company.

This knowledge will help you grasp better the details of the employee physical form before starting filling it out.

QuestionAnswer
Form NameEmployee Physical Form
Form Length1 pages
Fillable?Yes
Fillable fields39
Avg. time to fill out8 min 7 sec
Other namesphysical exam form for work pdf, physical exam form for work, physical examination form for work, physical form for work

Form Preview Example

P 908 312 1423 - www.fivestar.care - F 908 325 1975 216 River Avenue Suite 207 Lakewood, NJ 08701

EMPLOYEE PHYSICAL EXAMINATION FORM

PAGE 1

Last Name:

First Name:

Middle Initial: Today’s Date:

MEDICAL HISTORY: Do you now have, or have you ever had, any of the following:

 

 

 

YES

NO

 

 

YES

NO

 

 

1.

Arthritis / Rheumatism

 

 

10.

Hepatitis A; B; C; other Infections

 

 

 

 

2.

Asthma / Wheezing

 

 

11.

Hernia(s)

 

 

 

 

3.

Back Injury/ Chronic Back Pain

 

 

12.

Hypertension /High Blood Pressure

 

 

 

 

4.

Broken Bones / Fractures

 

 

13. Jaundice / Liver Disease

 

 

 

 

5.

Cancer

 

 

14.

Sinus Trouble / Allergies

 

 

 

 

6.

Diabetes

 

 

15.

Skin Disease

 

 

 

 

7.

Emphysema / Lung Disease

 

 

16.

Stomach Trouble / GI Problems

 

 

 

 

8.

Head Injury / Unconsciousness

 

 

17.

Substance Abuse (History of Drug

 

 

 

 

 

 

 

 

 

or Alcohol Abuse Problems)

 

 

 

 

9.

Heart Disease / Heart Attack

 

 

18.

Tuberculosis or History of Positive

 

 

 

 

 

 

 

 

 

TB Skin Test

 

 

 

I have read the above and declare that I have no injury, illness or ailment other than is specifically noted above. Any falsification or misrepresentation will be sufficient grounds for my release from employment.

Employee’s Signature

Date

Any “YES” answer(s), please explain below.

Put the number (1, 2, 3, etc.) of the YES answer before the explanation:

( Example: “#12. I have been taking medication for high blood pressure since 2007.”)

P 908 312 1423 - www.fivestar.care - F 908 325 1975 216 River Avenue Suite 207 Lakewood, NJ 08701

EMPLOYEE PHYSICAL EXAMINATION FORM

PAGE 2

Last Name:

 

 

 

 

 

 

 

First Name:

 

 

 

 

Middle Initial:

 

Today’s Date:

 

Job Title:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DOB

 

Age

 

Sex

 

HT

 

WT

 

Temp.

Pulse

Resp.

 

B/P

 

Drug/Food Allergies

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Vision: R 20/

 

 

L 20/

 

Pupils: Equal

 

Unequal Glasses/Lenses: Y / N

Hearing: Normal Impaired Hearing Aid

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PHYSICAL EXAM

 

 

 

NORMAL

 

ABNORMAL

 

 

 

COMMENTS

1.

General Appearance / BMI

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Skin

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

HEENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

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5.

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Lungs

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7.

Heart

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8.

Abdomen

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.

GU System

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10. Musculoskeletal Functioning

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Full ROM to all extremities? History

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

of injury to knees or hips?)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11. Back / Spine (History of injury?)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12. Neurological (Gross observation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

of gait, coordination, tremors, etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13. Psychiatric (tics, stuttering, nail-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

biting, cognition, orientation, affect,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

obvious personality disorders, etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Physician’s review of person’s medical history as recorded on reverse side of this form:

PPD / Mantoux Test for Tuberculosis: 1st Step Date:

 

 

 

_ Result:

_ 2nd Step Date:

Result:

 

Chest X-Ray: Date Performed:

 

 

Results:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

THIS APPLICANT IS FIT FOR EMPLOYMENT: YES:

 

 

 

 

NO:

 

 

Deferred for Functional Capacity Evaluation:

 

 

 

 

 

 

 

 

Examining Physician’s Signature

 

Date Physical Examination Performed

How to Edit Employee Physical Form

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example of fields in annual physical exam form for employment

You need to type in the crucial details in the NAME, FREQUENCY, INDICATION, REQUIRED TUBERCULOSIS SCREENING, Results_____, and Chest X-ray (If P space.

Finishing annual physical exam form for employment stage 2

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Filling in annual physical exam form for employment stage 3

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