Physical Examination Form PDF Details

A Physical Examination Form stands as a crucial document within various sectors, particularly when assessing an individual's capability to undertake specific roles that demand physical fitness and health. This comprehensive form encompasses a variety of sections, including Applicant Information, Health History, General Fitness and Health, and a Physician's Clearance. Initially, it collects basic but vital details about the applicant, such as name, date of birth, and contact information, setting the stage for a detailed examination. Following this, the form delves into an in-depth health history evaluation, meticulously examining aspects like the presence of diseases including asthma, muscular disease, psychiatric disorders, and any previous significant injuries or illnesses. Furthermore, it evaluates the applicant's general fitness, vision, hearing, and even specific conditions like tuberculosis or diabetes. The examining physician is required to provide detailed observations and, if necessary, explanations for any affirmative answers regarding the applicant's health issues. Ultimately, the form concludes with the physician's clearance, determining whether the individual is qualified for their intended role, possibly with specific conditions such as the need for corrective lenses or a hearing aid. This form not only ensures the individual's safety and readiness but also aligns with regulatory compliance, safeguarding both the applicant and the organization or authority requesting the examination.

QuestionAnswer
Form NamePhysical Examination Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesnyc dob lic61, medical examination form doc, physical examination form for adults, physical examination form for adults nyc

Form Preview Example

PHYSICAL EXAMINATION FORM

1

Applicant Information

 

 

 

 

 

 

 

 

 

 

First Name

 

Last Name

 

 

 

 

 

 

Date of Birth

*Social Security #

 

 

 

 

 

 

Home Address

Phone Number

 

 

 

 

 

 

 

 

 

City

 

State

 

Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

License Number

 

 

 

License

Type:

(if, licensed)

 

 

2

Health History

 

TO BE FILLED IN BY EXAMINING PHYSICIAN (Please print)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

Yes No

Yes

No

 

 

 

 

 

 

 

 

 

 

Asthma

Muscular Disease

 

Head or spinal injuries

 

 

 

 

 

 

 

 

 

 

Kidney

Psychiatric Disorder

 

Seizures, fits, convulsions or fainting

 

 

 

 

 

 

 

 

 

 

Tuberculosis

Cardiovascular Disease

 

Extensive confinement by illness or injury

 

 

 

 

 

 

 

 

 

 

Diabetes

Gastrointestinal Ulcer

 

Any other nervous disorder

 

 

 

 

 

 

 

 

 

 

Nervous Stomach

Ethanol use

 

Suffering from any other disorder

 

 

 

 

 

 

 

 

 

 

Rheumatic Fever

Rx drug use

 

Permanent defect from illness, disease or injury

 

 

 

 

 

 

 

 

 

 

Over the counter drug use

 

 

 

 

 

 

 

 

 

 

IF ANSWER TO ANY OF THE ABOVE IS YES, EXPLAIN:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

General Fitness and Health:

Good

Fair

Poor

 

Vision:

 

For Distance:

Right/20

Both/20

Without Corrective Lenses

 

 

 

 

 

 

 

 

 

 

 

 

 

 

With Corrective Lenses

 

 

 

 

 

 

 

 

Evidence of disease or injury

Right _______________________________

Left ______________________________________

 

 

 

 

 

 

 

Color Test

_________________________________________________________________________________

 

 

 

 

 

 

 

 

 

Horizontal Field of Vision:

Right _______________________________

Left _______________________________________

 

 

 

 

 

 

 

Hearing:

 

Right _______________________________

Left _______________________________________

 

 

 

 

 

 

 

 

Evidence of disease or injury

Right _______________________________

Left _______________________________________

 

 

 

 

 

 

 

 

 

 

Audiometric Test:

Decibel loss at

500HZ

1,000 HZ

2,000 HZ

3,000 HZ

4,000 HZ

 

 

 

 

 

 

Throat:

 

_________________________________________________________________________________

 

 

 

 

 

 

 

Thorax:

Heart:

_________________________________________________________________________________

 

 

 

 

 

If organic disease is present, is it fully compensated? _________________________________________________________________________________

 

 

 

 

 

 

 

 

Blood Pressure:

Systolic ____________________________

Diastolic _________________________________

 

 

 

 

 

 

 

Pulse:

Before Exercise _____________________ Immediately after ___________________________

 

 

 

 

 

 

 

Lungs:

_________________________________________________________________________________

 

 

 

 

 

 

 

 

Abdomen:

Scars

_________________

Abdominal Masses _________________ Tenderness ________________

 

 

 

 

 

 

 

 

 

Page 3

 

 

 

 

 

LIC 61 5/2015

PHYSICAL EXAMINATION FORM (CONT’D)

2

Health History (cont’d)

TO BE FILLED IN BY EXAMINING PHYSICIAN (Please print)

Hernia:

Yes

No

If so, where? ____________________________

Is truss worn? ___________________________

Gastrointestinal:

Ulceration or other disease?

Yes

____________________________

No

___________________________

 

 

 

 

 

 

Genito-Urinary:

Scars:

________________________

 

Urinal Discharge:

___________________________________________

 

 

 

Reflexes:

Rhomberg:

_____________________________________________________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

L

 

 

Pupillary:

________________________

Light:

R __________________________

___________________________

 

 

 

 

 

 

 

 

 

 

 

Accommodation:

_____________________________

R __________________________

L

 

 

___________________________

 

 

 

 

 

 

 

 

 

 

Knee Jerks:

 

Right

 

Normal

______________

Increased

______________

Absent

_____________

 

 

 

 

 

 

 

 

 

 

 

 

Left

 

Normal

______________

Increased

______________

Absent

_____________

 

 

Remarks:

________________________________________________________________________________________________________________

 

 

 

 

 

 

 

Extremities: Upper

____________________

 

Lower

_____________________

Spine

_____________________

 

 

 

 

Laboratory &

Urine Spec. Gr. _____________________

Alb. ___________________________

Sugar __________________________________

Other Special

Other Laboratory Data (Serology, etc.) _________________________________________________________________________________

Findings:

Radiological Data ____________________________________

Electrocardiograph ___________________________________________

 

General

Comments:

3

Physician

TO BE FILLED IN BY EXAMINING PHYSICIAN (Please print)

 

Name of Physician

Phone # of Physician

 

 

 

 

 

 

Address of Physician

 

 

 

 

 

 

 

City

State

Zip

 

 

 

 

 

Physician’s Signature

_________________________________________ Date

_______________________________________

 

 

 

 

4

Physician’s Clearance

 

Physician’s Clearance

TO BE FILLED IN BY EXAMINING PHYSICIAN (Please print)

 

 

 

 

 

 

 

I certify that I have examined:

 

 

 

 

 

 

 

 

 

with the knowledge of his/her duties, I find him/ her :

 

 

 

 

 

 

 

 

 

 

Qualified to perform work in their trade, pursuant to license regulations. (see addendum)

 

 

 

 

 

 

 

 

 

 

Qualified,

only when wearing a hearing aid.

NOT Qualified, provide a typewritten, signed explanation.

 

 

 

 

 

 

 

 

 

 

Qualified,

only when wearing corrective lenses

 

 

 

 

 

 

 

 

A complete examination form for this person is on file in my office:

 

 

 

 

 

 

 

 

Address of Examination

 

 

 

 

 

 

 

 

 

Date of Examination

Name of Physician

 

 

 

 

 

 

 

 

Signature of Physician

 

 

 

 

 

 

 

 

 

 

Name of Applicant

 

 

 

 

 

 

 

 

 

 

Signature of Applicant

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 2

*In accordance with Federal and State Laws, the New York City Department of Buildings requires that all applicants for licenses/license holders provide their Social Security Number

LIC61 5/2015

 

(SSN). DOB will use the SSN to conduct background investigations and maintain accurate license and related records. This information may be shared with other government agencies,

 

consistent with applicable laws and Departmental policy or with the SSN holder’s written permission, but will otherwise be kept confidential. The specific statutory authority for requiring SSN’s is in the following: Federal Law-Privacy Act of 1974 (Section 7 of P.L., 93-579); Welfare Reform Act of 1996 (42 USCA 666(a)), and Section 5 of the NYS Tax Law.

 

PHYSICAL EXAMINATION FORM

Addendum: License Regulations

 

 

License Type

Relevant Regulations

 

 

Hoist Machine Operator

This license authorizes a NYC licensee to take charge of or operate power operated hoisting machines

 

(depending on the class of license) used for hoisting purposes or cableways under the jurisdiction of the De-

 

partment. Including but not limited to cranes.

 

NYC Administrative Code Section 28-405; Title 1 of the Rules of the City of New York Section 104-09

 

 

Rigger

This license authorizes a NYC licensee to hoist or lower an article outside of any building in the city. Including

 

the use of suspended scaffolds. Tower or climber crane rigger licensees may supervise the erection and dis-

 

mantling of tower or climber cranes.

 

NYC Administrative Code Section 28-404; Title 1 of the Rules of the City of New York Section 104-10

 

 

Welder

This license authorizes a NYC licensee to perform manual welding work on any structural member of any

 

building in the city.

 

NYC Administrative Code Section 28-407; Title 1 of the Rules of the City of New York Section 104-11

 

 

Site Safety Manager; Site Safety

This license authorizes a NYC licensee to ensure compliance with the site safety plan and all safety require-

Coordinator

ments, as specified in chapter 33 of the New York City Building Code.

 

NYC Administrative Code Section 28-402; NYC Administrative Code Section 28-403

 

 

Private Elevator Inspection Agency

This license authorizes a NYC licensee to perform and/or witness inspections and tests or enter into contracts

Inspector; Private Elevator Inspec-

pursuant to article 304, chapter 3 of the NYC Administrative Code.

tion Agency Director

NYC Administrative Code Section 28-421; NYC Administrative Code Section 28-422

 

 

 

Sign Hanger

This license authorizes a NYC licensee to hoist lower or to hang or attach any sign, irrespective of weight,

 

upon or on the outside of any building or structure in the city. This may include the use of cranes and/or sus-

 

pended scaffolds.

 

NYC Administrative Code Section 28-415

 

 

High Pressure Boiler Operating En-

This license authorizes a NYC licensee to operate any high-pressure boiler in the city of New York. Excluding

gineer

the exceptions listed in NYC Administrative Code.

 

NYC Administrative Code Section 28-413

 

 

Oil Burning Equipment Installer

Class A: Authorizes installation of any type of oil-burning in the city, as an independent contractor with full

 

responsibility for the manner in which the work is done, for the materials and equipment used, and for the con-

 

trol and direct and continuing supervision of the persons employed on the work. Such equipment shall include

 

but not be limited to burners, boilers and generators.

 

Class B: Authorizes installation of oil-burning equipment for the use of domestic fuel oils from number one fuel

 

oil to and including number four fuel oil, as an independent contractor with full responsibility for the manner in

 

which the work is done, for the materials and equipment used, and for the control and direct and continuing

 

supervision of the persons employed on the work.

 

NYC Administrative Code Section 28-412

 

 

Master Plumber

This license authorizes a NYC licensee to perform plumbing work. Except that a city employee who holds a

 

master plumber license may only perform replacement, maintenance and repair plumbing work on existing

 

buildings in the course of his or her employment.

 

NYC Administrative Code Section 28-408

 

 

Master Fire Suppression Piping

This license authorizes a NYC licensee to perform fire suppression work, except that a city employee who

Contractor

holds a master fire suppression license may only perform replacement, maintenance and repair fire suppres-

 

sion piping work on existing buildings in the course of his or her employment.

 

NYC Administrative Code Section 28-410

 

 

Page 3

LIC 61 5/2015

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Part # 1 in completing power of attorney affidavit

2. Soon after the prior section is completed, go on to enter the suitable information in all these: IF ANSWER TO ANY OF THE ABOVE IS, General Fitness and Health, Vision, Good, Fair, Poor, For Distance Right, Both, Without Corrective Lenses, With Corrective Lenses, Evidence of disease or injury, Left, Hearing, Right Left, and Horizontal Field of Vision Right.

General Fitness and Health, Both, and Poor inside power of attorney affidavit

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Filling out segment 3 in power of attorney affidavit

4. Completing PHYSICAL EXAMINATION FORM CONTD, Hernia Yes No, If so where, Is truss worn, Gastrointestinal Ulceration or, GenitoUrinary Scars, Urinal Discharge, Reflexes Rhomberg, Knee Jerks, Pupillary, Light R, Accommodation, Right Normal, Increased, and Absent is paramount in the fourth form section - ensure to take your time and take a close look at each blank area!

Filling in segment 4 in power of attorney affidavit

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Date, Physicians Clearance, and Name of Physician inside power of attorney affidavit

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