HEALTH EXAM

EMPLOYEE HEALTH EXAMINATION
I have examined
and have found no condition that
appears to prevent him/her from performing the duties of
Further, I have found him/her to be free from infectious, communicable or contagious diseases.
Date

MonthDayYear
Date
Physician Name:
Signature

Clear
Address
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

TEST (if taken)

Rows	Date Performed	Results
Chest X‐Ray PPD
VDRL‐serology (Not required)
Stool Culture (Required for all kitchen employees)
Blood Count (Recommended but not required)
Urinalysis (Recommended but not required)