Pre- Employment Physical (PA)

XINCON HOME HEALTH CARE SERVICES INC.

EMPLOYEE PHYSICAL EXAMINATION REPORT
Pre-Employment Physical Assessment Annual Assessment Return to work/LOA
Name:
Marital Status:

M S W D
Sex:

M F
Address
SS #:
Title:
PHYSICAL EXAMINATION
HEIGHT:
WEIGHT:
BLOODPRESSURE:
HEAD/ENT:
EYES:
NECK:
BREASTS:
LUNGS
PULSE:
RESP:
TEMPERATURE:
CARDIOVASCULAR:
MUSCULOSKELETAL:
ABDOMEN:
GENITOURINARY:
CENTRAL NERVOUS SYSTEM:
COMMENTS:
LABORATORY TEST RESULTS
1st PPD/MANTOUX

(2nd Step Required if Result Is Negative)
1.DATE IMPLANTED:

Month Day Year
Date
LOT#:
2.DATE READ:

Month Day Year
Date
LOT#:
RESULTS (mmXmm):
RESULTS (mmXmm):

NEGATIVE(-) POSITIVE(+)
PPD/MANTOUX 2nd Step

(If 1st Step PPD is NEGATIVE)
1.DATE IMPLANTED:

Month Day Year
Date
LOT#:
2.DATE READ:

Month Day Year
Date
LOT#:
RESULTS (mmXmm):
RESULTS (mmXmm):

NEGATIVE(-) POSITIVE(+)
CHEST X-RAY

(1st (If 1 Step PPD is POSITIVE)
DATE:

Month Day Year
Date
RESULTS:

NEGATIVE(-) POSITIVE(+)
(PLEASE ATTACH LAB REPORTS)
DRUG SCREEN (ANNUALLY)

(*ATTACH LAB REPORT)
DATE:

Month Day Year
Date
RESULTS:

NEGATIVE(-) POSITIVE(+)
(PLEASE ATTACH LAB REPORTS)
IMMUNIZATIONS
RUBELLA TITTER (*ATTACH Lab Report)

If not immune, please provide MMR Vaccine
LAB VALUE:

NON-IMMUNE IMMUNE
1.
RUBEOLA/MEASLES TITTER (*ATTACH Lab Report)

(only if born on or after 1/1/1957)

If not immune, please provide MMR Vaccine
LAB VALUE:

NON-IMMUNE IMMUNE
1.
2.
HEPATITIS B VACCINE
1.
2.
3.
INFLUENZA VACCINE (ANNUALLY MANDATORY)
Date Received:

Month Day Year
Date
Type of Vaccine:
Dose:
Name of Administrator:
H1N1 VACCINE (Mandatory when available)
Date Received:

Month Day Year
Date
Type of Vaccine:
Dose:
Name of Administrator:
Type a question

This individual is free from any health impairment that is a potential risk to the patient or other employee or which may interfere with the performance of his/her duties including the habituation or addiction to drugs or alcohol. This individual is able to work with the following limitations: This individual is not physically/mentally able to work (Specify Reason):
Physician Signature:

Clear
Lic. #:
Date:

Month Day Year
Date
Xincon RN Signature:

Clear
Date:

Month Day Year
Date
Should be Empty:

XINCON HOME HEALTH CARE SERVICES INC.

PHYSICAL EXAMINATION

LABORATORY TEST RESULTS

IMMUNIZATIONS