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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

Question	Answer
Form Name	Pre Employment Physical Form
Form Length	4 pages
Fillable?	Yes
Fillable fields	357
Avg. time to fill out	36 min 12 sec
Other names	pre 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

Sex

In Emergency Notify	Relationship	Phone Number

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

YES

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

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

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

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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Pre Employment Physical Form – Fill Out and Use This PDF

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Pre Employment Physical Form – Fill Out and Use This PDF

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