PRE-EMPLOYMENT PHYSICAL EXAMINATION

NR. ___________

Patient Name ____________________________________________________Date of Birth________________________

Gender ________ Marital Status ________________ Language____________ Ethnicity__________ Race ____________
Address___________________________________________ City___________ State ____________ Code ___________
Home Phone_____________________ Cell Phone_______________________ Work Phone _______________________
Email Address______________________________________________________________________________________

REVIEW OF SYSTEMS

Do you have any of the following? Yes No Yes No

Fevers Loss of memory
Headaches Chest Pain or tightness
Difficulty with vision / Wear lenses or glasses Abdominal pain
Dizziness / Vertigo Kidney Stones
Tiredness or falling asleep during the day Back pain
Unable to tolerate heat or cold Joint pain or swelling
Shortness of breath with or without exertion History of broken bones
Sneezing Swelling of the legs
Cough Skin problems (rash, eczema, psoriasis)
Allergies High Blood Pressure
Carpal Tunnel Syndrome Diabetes

Do you smoke? If yes, what do you smoke and how many per day? __________________________________
Do you drink alcohol? If yes, what do you drink and how much? _________________________________________

Vaccination
___________________________________________________________________________________________

Current Medical Conditions (List those that you are currently receiving treatment for. Date, month and year)
___________________________________________________________________________________________

Do you have allergies to any medications or other substances? If yes, please specify.
___________________________________________________________________________________________

Please list prescribed medications and over the counter medications that you take.
___________________________________________________________________________________________

Are you currently under the treatment or care of a physician or other health care provider?
___________________________________________________________________________________________

Do you have any condition (physical, medical, or psychological) that would require special accommodations in
order for you to preform your job? If yes, please specify.
___________________________________________________________________________________________

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 PHYSICAL EXAMINATION

Height _______________________________________________________________________________
Weight _______________________________________________________________________________
Vision Uncorrected / Corrected Right Eye _________ Left Eye __________ Both Eyes ____________
Neck _______________________________________________________________________________
Chest/Lungs _______________________________________________________________________________
Heart _______________________________________________________________________________
Abdomen _______________________________________________________________________________
Musculoskeletal _______________________________________________________________________________
Neurological _______________________________________________________________________________
Skin _______________________________________________________________________________
Other _______________________________________________________________________________
_______________________________________________________________________________

Physician’s Clearance TO BE FILLED IN BY THE EXAMINING PHYSICIAN

I certify that I have examined:

With the knowledge of his/her duties, I find him / her qualified. Please choose one:

Medically fit

Medically fit with accommodations - (Please attach Accommodation Statement)

Not medically fit

Address of Examination

Date of Examination Name of Physician

Signature of Physician Physician’s Stamp

I, as an applicant, authorize the release to my Name of Applicant Signature of Applicant

licensing authority of all information
contained on this examination form and all
other forms generated as a direct result of my
examination.

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