New Hire Medical History and Physical Form
Employee Name
*
First Name
Last Name
Employee Email:
example@example.com
Date of Birth:
*
-
Month
-
Day
Year
Date
Employee's Physician/Doctor Name:
*
Doctor/Physician Phone Number:
*
-
Area Code
Phone Number
List any drug/medication allergies:
*
List other allergies:
*
Personal Medical History-have you had or do you now have any of the following:
*
Yes
No
Shortness of Breath
Chest or Heart Pain
Asthma
Chronic Bronchitis
Frequent colds/cough
Health disease/murmurs
Blood pressure issues
Breast problems
Rheumatic fever
Mumps
Measles
Chicken Pox
Kidney trouble
Painful or bloody urination
Back Pain/Back injury
Cancer/Tumor
Dizziness or fainting
Anemia or blood disease
Thyroid issues
Diabetes
Arthritis/Joint Issues
Chronic diarrhea or bowel trouble
Liver issues/Hepatitis
Stomach ulcer
Vomiting blood/Black stool
Recent gain or loss in weight
Hemorrhoids
Hernia
Deafness/Impaired hearing
Eye trouble
Epilepsy/Seizures
Emotional or Psychiatric Problems
Frequent or severe headaches
Permanent disability due to birth/accident/disease
MS
Tuberculosis
Skull or other bone fractures
Explanation for any area with "YES" answer above:
List any hospital admissions/surgeries: (approximate date and reason)
*
Have you ever received workers compensation for an industrial injury or disease?
*
Yes
No
If yes, who was employer at the time?
Have you ever had an injury caused by your work or military service?
*
Yes
No
In accordance with the job description for this position, do you have any condition that does or may limit your ability to complete the essential functions of your assigned job?
*
Yes
No
If answered yes-please explain:
Employee Acknowledgement:
Employee Signature:
*
Submit
Form Complete?
Yes
No
Back
Next
Employee Physical Form
***To be completed by examiner and Physician
Date of examination:
-
Month
-
Day
Year
Date
Employee Blood Pressure:
Employee Pulse:
Any concerns raised during assessment:
Person completing assessment:
First Name
Last Name
Title of person completing assessment:
Physician Acknowledgement:
Physician Signature
Submit
Should be Empty: