PHYSICAL EXAMINATION REPORT / ANNUAL PHYSICAL EXAMINATION FORM

Patient Information
PHYSICAL EXAMINATION REPORT
Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
SSN (Last 4)
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone
Please enter a valid phone number.Format: (000) 000-0000.

Physical Examination Report
Head Comments
Eyes Comments
Neck Comments
Throat Comments
Lungs Comments
Heart Comments
Abdominal Comments
Extremities Comments
Cardiovascular Comments
Musculoskeletal Comments
Skin Comments
Central Nervous System Comments
Height (HT)
Weight (WT)
Blood Pressure (B/P)
Pulse
Respirations
Temperature

BASELINE INDIVIDUAL TB RISK ASSESSMENT
Residence >1 month in a country with a high TB rate
Current or planned immunosuppression
Close contact with someone who had infectious TB disease since the last TB test

INFLUENZA VACCINE
Influenza Vaccine
Declination Signature
Influenza Vaccine Date

MonthDayYear
Date
Influenza Vaccine Lot #

Health Status
Health Status

III. REVIEW OF SYSTEMS (To be Completed by Doctor)
EENT
Head/Neck
Cardiovascular
Respiratory
Abdomen - GI
Genitourinary
Musculoskeletal
Neurologic
Endocrine
Skin
Height (cm)
Weight (kg)

V. Doctor Certification
Certification Statement(s)
Work Limitations
Reason Not Fit for Work
Physician's Name

First NameMiddle NameLast Name
Physician's Signature
License Number
Date

MonthDayYear
Date
Should be Empty: