Pre-Employment Medical Examination

Personal Information
Name:
Date:

Month Day Year
Date
Address:
Phone
Email:
example@example.com
DOB:
Ethnicity:
Weight:
Sex:
Primary Physician:
Insurance Provider:
Phone:
ID No.
Employment
Job Title:
Department:
EIN:
Dates:

Month Day Year
Date
Previous Employer:
Current Symptoms (Check All That Apply)

Headaches Joint Pain/Swelling Dizziness/Palpitations Numbness/Tingling/Weakness Nausea/Vomiting Vision Impairment Hearing Impairment Weight Loss/Gain Fevers/Chills/Night sweats Coughing/Wheezing/Shortness of breath Fatigue Chest Pain/Back Pain/Abdominal Pain
Medical History
Exercise Frequency:
Exercise Type(s):
Smoking Frequency:
Drinking Frequency:
Illicit Drug Frequency:
Fast Food Frequency:
Allergies:
Current Diagnoses:
Current Medications:
Current Injuries:
Previous Medications:
Previous Injuries:
Dates Treated:

Month Day Year
Date
Previous Surgeries:
Problems
Vitals: T: P: RR: BP: Oxygen sat: Weight: Height: BMI:
Height:
Drug Screen:

Positive Negative Drug Screen:
Negative Drug Screen:
Drug Screen:
Vaccinations
Provide Dates of Standard Childhood Vaccinations
Hepatitis A
Hepatitis B
Tuberculosis
Influenza
MMR
Td or Tdap
Chicken Pox (vaccine or illness)
Occupational Hazards
Do you require a respirator, face mask, or nose/mouth guard? Will you be lifting more than fifty pounds on a regular basis?
Will you be exposed to human fluids (blood, feces, etc.)?
Will you be exposed to poisonous or radioactive chemicals?
Will you be operating heavy machinery/driving a vehicle?
My signature below is to confirm that I have provided accurate medical information to Minneapolis Health Clinic for my pre-employment physical examination.
Signature

Clear
Date

Month Day Year
Date
Should be Empty:

Personal Information

Employment

Medical History

Vaccinations

Occupational Hazards