Employee Physical Form
Patient Information
Full Name
*
Marital Status
*
M
S
ID
*
Complete Address
*
Social Security Number
*
Physical Examination
HEAD:
CARDIOVASCULAR:
EYES:
MUSCULUOSKELETAL:
NECK:
ABDOMEN:
BREASTS:
GENITOURINARY:
LUNGS:
CENTRAL NERVOUS SYSTEM:
COMMENTS:
Sex
*
M
F
HT:
*
WT:
*
B/P:
*
PULSE:
*
RESP:
*
TEMP:
*
LABORATORY TEST RESULTS
PPD1-DATE-IMPLEMENTED
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Month
-
Day
Year
Date
PPD1-DATE-READ
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Month
-
Day
Year
Date
PPD1-RESULTS
PPD2-DATE-IMPLEMENTED
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Month
-
Day
Year
Date
PPD2-DATE-READ
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Month
-
Day
Year
Date
PPD2-RESULTS
IF your patient has previously tested positive for tuberculosis either via a tuberculin skin test or a Quantiferon type blood test:
A new chest x-ray IS required to rule out active tuberculosis
A new chest x-ray is NOT required to rule out active tuberculosis
TB-GOLD-QUANTIFERON
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Month
-
Day
Year
Date
CHEST-X-RAY
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Month
-
Day
Year
Date
RUBELLA-TITER NEW HHA
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Month
-
Day
Year
Date
RUBEOLA-TITER NEW HHA
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Month
-
Day
Year
Date
RUBELLA (ONE DOSE REQUIRED) – NEW HHA
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Month
-
Day
Year
Date
RUBEOLA/MEASLES (TWO DOSES REQUIRED) - NEW HHA:
Dose #1
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Month
-
Day
Year
Date
Dose #2
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Month
-
Day
Year
Date
INFLUENZA
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Month
-
Day
Year
Date
INFLUENZA-MANUFACTURER
INFLUENZA-LOT-NUMBER
INFLUENZA-VOL(ml)
INFLUENZA-ROUTE
INFLUENZA-SITE
INFLUENZA-EXP-DATE
-
Month
-
Day
Year
Date
Tuberculosis (TB) Screen – Has patient had the following symptoms?
CHEST PAIN
YES
NO
WEIGHT LOSS
YES
NO
LOSS OF ENERGY
YES
NO
LINGERING COUGH
YES
NO
BLOOD IN SPUTUM
YES
NO
INCREASED SWEATING AT NIGHT
YES
NO
HEALTH-IMPAIRMENT-FREE[]
This individual is free from any health impairment that is a potential risk to a patient or which might interfere with the performance of his/her duties, including the habituation or addiction to depressants, stimulants, narcotics, alcohol or other drugs or substances which may alter the individual’s behavior.
CHAIN OF CUSTODY DRUG SCREEN
This individual is free from any health impairment that is a potential risk to a patient or which might interfere with the performance of his/her duties, including the habituation or addiction to depressants, stimulants, narcotics, alcohol or other drugs or substances which may alter the individual’s behavior.
Confirmed
This individual is able to work with the following limitations:
LIMITATIONS
This individual is not physically/mentally able to work:
NOT-ABLE-WORK-REASON
Physician Signature
*
License
*
Date
*
-
Month
-
Day
Year
Print Name Here
*
Address
*
Phone Number
*
Please enter a valid phone number.
Please verify that you are human
*
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