Pre Employment Physical Form Pdf Details

A pre employment physical form is a document that is filled out by an employee and their doctor before the employee is hired. The form contains information about the employees health, including any conditions that could affect their ability to work. This form allows the employer to make a judgement about whether or not the employee is able to do the job they are applying for. There are many different types of pre employment physical forms, and each one will vary depending on what type of job you are applying for. Some forms may be more detailed than others, but all of them will require basic information about your health history. It's important to fill out this form accurately and honestly, so that your potential employer can make an informed decision about hiring you.

Listed below are some particulars about pre employment physical form. There, you'll get the information about the PDF you would like to fill in, along with the assumed time to fill it out and also other partic

QuestionAnswer
Form NamePre Employment Physical Form
Form Length4 pages
Fillable?Yes
Fillable fields357
Avg. time to fill out36 min 12 sec
Other namespre employment physical forms, physical form for work, pre employment physical form, pre employment physical form printable

Form Preview Example

NEW YORK UNIVERSITY

PRE EMPLOYMENT PHYSICAL

Human Resource Department only:

Name of HR Representative scheduling Exam:______________________

Date Scheduled:___________________

To Be Completed by Prospective Employee PRIOR TO APPT:

PRINT Last Name

First Name

Middle Initial

 

 

 

 

Address

City

State

Zip Code

 

 

 

 

Phone Number

 

 

 

Department:_____________

Job Type:_______________

Date

Age

Date of Birth

MF

Sex

In Emergency Notify

Relationship

Phone Number

 

 

 

PLEASE COMPLETE THE FOLLOWING PRIOR TO SEEING PROVIDER - LEAVE NO BLANK SPACES:

YES

NO

DON'T KNOW

Frequent Headaches

Eye or Ear Infections

Throat Trouble

Sinus Trouble

Thyroid Problems

Frequent Colds

Lumps or Tumors in Neck

Asthma

Pneumonia

Pleurisy

Spitting up Blood

Coughing up Blood

Chronic Cough

Lung Trouble

Tuberculosis

Shortness of Breath

Chest Pains

Rheumatic Fever

Heart Murmur

Swelling of Ankles

Low Blood Pressure

Stomach Trouble

Heartburn

Vomiting Blood

Black Bowel Movements

Blood in Stools

Frequent Diarrhea

Abdominal Pains

Gallbladder Trouble

Liver Trouble

Hepatitis or Jaundice

Piles, Hemorrhoids

Tropical Disease or Worms

Hernia or Rupture

Kidney Trouble

Kidney Stones

Blood in Urine

YES

NO

DON'T KNOW

Bladder Infections

Frequent Urination

Broken Bones

Back Sprains or Surgery

Arthritis

Deformities of Joints

Deformities of Bones

Missing Fingers or Toes

Ruptured Disc in Back

Skin Rashes

Skin Tumors

Head Injury

Epilepsy or Fits

Frequent Dizziness

Paralysis

Loss of Memory

Diabetes or High Sugar

Sugar in Urine

Allergies

Allergic reaction to food

Allergic reaction to Drugs

Anemia

Polio

Recent Weight Loss

Recent Weight Gain

Fatigue

Depression

Anxiety or Panic Attacks

Change in Activity Level

High Blood Pressure

Chronic Bronchitis

Muscle Pain

Sleeping Problems

Breast Lumps

Loss of Consciousness

Excessive Thirst

NEW YORK UNIVERSITY

PRE EMPLOYMENT PHYSICAL

NAME:_____________________________________________

Have you ever:

Suffered from hearing problems or hearing loss Suffered from visual problems or eye diseases Had back problems, back pain or back injuries Had foot problems

YES

NO

Have you ever been a patient in a hospital for any reason? YES NO

If YES, please complete the following section:

NAME OF HOSPITAL

CONDITION TREATED FOR

DATES

1

2

3

4

5

6

7

8

Have you ever lost time from work in the past year for ANY REASON? YES NO

If YES, Please explain:

Are you currently uder the treatment or care of a physician, Nurse Practitioner or other health care provider in the past year? If YES, Please explain:

Do you SMOKE?

YES

NO

If YES -

What do you smoke?______________ How many per day?__________________ How many years?_________________

Do you drink ALCOHOL?

YES NO

If YES -

How many drinks do you drink at each sitting?______________ How many days per week?____________

What do you drink?

BEER WINE HARD LIQUOR OTHER:____________________________________________

Are you taking prescribed or over the counter medications, herbal products, vitamins or supplements?

MALES ONLY:

 

 

Have you now or have you ever had a HERNIA or RUPTURE OF A HERNIA?

YES

NO

Have you ever had a Sexually Transmitted Disease? Gonorrhea Syphilis

Chlamydia

Have you ever had problems with your testicles (surgery, infection, injury)?

YES

NO

FEMALES ONLY:

Have you now or have you ever had any problems with your breasts (lumps, tumors, surgery)? YES NO

Are you now or have you ever been pregnant? YES

NO If YES, how many pregnancies?_________ Miscarriages?_________

Are your periods regular? YES NO Do you have pain with your periods?

YES NO Date of Last Period__________________

Have you ever had a Sexually Transmitted Disease?

Gonorrhea Syphilis

 

NEW YORK UNIVERSITY

PRE EMPLOYMENT PHYSICAL

NAME:_____________________________________________

VACCINATION HISTORY:

 

Last known Tuberculin Skin Test? _________ Results:

Negative Positive - If positive was a Chest X ray done? YES NO

 

If YES - Results of Chest x ray?__________________

Last Tetanus Shot________________________

Hepatitis B Vaccination YES NO If YES, when?________________

What is your private healthcare providers name?

Address:

Phone number:

I give permission to the screening healthcare provider at New York University Health Center to forward any abnormal findings to my healthcare provider. I understand that I am responsible for following up with my own healthcare provider on any abnormal findings that arise during the pre-employment physical conducted by the healthcare screening provider at NYU. I understand that NYU will not provide follow-up treatment for such findings.

PRINT NAME

SIGNATURE

DATE

The information contained in this form is of a strictly confidential nature. The form will remain in the New York University Health Center confidential files and may be seen only by the examining healthcare provider, nurses in attendance and administrative personnel reviewing the chart for quality assurance reasons. I hereby declare the answers I have given are to the best of my knowledge.

PRINT NAME

 

 

 

SIGNATURE

DATE

 

 

 

 

 

TO BE COMPLETED BY UHC PROVIDER:

 

 

 

 

 

 

 

NEW YORK UNIVERSITY HEALTH CENTER

 

 

 

PRIMARY CARE SERVICE PROVIDER

 

VITAL SIGNS:

BP_________

HR________ HEIGHT:_________

WEIGHT:____________

 

VISUAL ACUITY

WITH WITHOUT

CORRECTION:

 

 

 

RIGHT EYE

20/

 

 

 

 

LEFT EYE

20/

 

 

 

 

BOTH EYES

20/

 

 

GENERAL APPEARANCE: NEAT POOR HYGIENE

OBESE THIN

AVERAGE

 

PPD IMPLANT DATE:______________

SITE:_____________

 

 

PPD READING DATE:______________

NEGATIVE

________ MM INDURATION

 

 

 

POSITIVE

________ MM INDURATION

CXR DATE:__________

 

 

 

 

 

 

CLEARED/XRAY NORMAL

 

 

 

 

 

 

NOT CLEARED - REFER TO PMD

LAB DATA:

 

 

HGG:_______________

HCT:_______________

WBC:_____________

URINE: SUGAR:____________

ACETONE:_______________

ALBUMIN:____________

SEROLOGY / RPR:_______________

 

 

NEW YORK UNIVERSITY

 

 

PRE EMPLOYMENT PHYSICAL

NAME:_____________________________________________

 

 

 

 

 

 

GENERAL APPEARANCE: NEAT POOR HYGIENE OBESE THIN AVERAGE DISTRESS NO DISTRESS

 

 

 

NORMAL

SYSTEM

ABNORMAL WITH COMMENTS:

 

 

 

 

HEAD

 

 

EYES

 

 

EARS

 

 

NOSE

 

 

MOUTH

 

 

NECK

 

 

CHEST

 

 

BREASTS

 

 

HEART

 

 

LUNGS

 

 

ABDOMEN

 

 

RECTAL

DEFERRED (circle if deferred)

 

GENITALIA

DEFERRED (circle if deferred)

 

EXTREMITIES

 

 

SPINE

 

 

NEURO

 

 

SKIN

 

 

PSYCH

 

ADDITIONAL FINDINGS:

FOLLOW UP REQUIRED:

_______________________________________

_______________________________________

DATE:__________

EXAMINING PROVIDER (PRINT)

EXAMINING PROVIDER SIGNATURE

 

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